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RG524  L38  Talks  on  obstetrics. 


■ON  OBSTETRICS 

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TALKS  ON  OBSTETRICS 


TALKS  ON  OBSTETRICS 


BY 
RAB  THORNTON  LA  VAKE,  M.D. 

Instructor    in    Obstetrics    and    Gynecology,    University    of    Minnesota; 
Obstetrician-in-Charge    of   the   Out-Patient   Obstetric    Department    of 
the  University  of  Minnesota ;  Associate  Attending  Obstetrician 
and  Gynecologist  to  the  Minneapolis   City  Hospital;   Obste- 
trician-in-Charge  of   the   Out-Patient    Obstetric   Depart- 
ment   of    the    Wells    Memorial    Dispensary;    Obste- 
trician  to   the   Swedish   and   Abbott  Hospitals, 
Minneapolis;    One    Time    Assistant    Resi- 
dent Obstetrician  to  the   Sloane  Hos- 
pital  for    Women   in   New   York. 


ST.  LOUIS 

C.  V.  MOSBY  COMPANY 

1917 


Copyright,  1917,  By  C.  V.  Mosby  Company 


Press   of 

C.  V.  Mosby  Company 

St.  Louis 


PREFACE 


In  presenting  this  little  book  to  undergrad- 
uate students  and  to  practitioners,  I  wish  to 
make  it  clear  that  it  is  intended  as  a  mere  sup- 
plement to  the  textbooks  and  is  in  no  way  a 
substitute  for  them  or  comparable  to  them. 

I  wish  to  acknowledge  my  indebtedness  to 
the  following  men  who  have  directly  aided  me 
in  all  my  work  since  my  association  with  them 
by  their  continued  courtesies,  interest,  and 
advice. 

To  Dr.  J.  C.  Litzenberg,  Head  of  the  Depart- 
ment of  Obstetrics  and  Gynecology  at  the  Uni- 
versity of  Minnesota,  who  has  ever  given  me 
free  access  to  all  cases  and  records  at  the  Uni- 
versity Hospital  and  aided  me  in  my  work  in 
the  Out-Patient  Department  in  every  way  pos- 
sible. 

To  Dr.  F.  L.  Adair,  Chief  of  Staff  in  Obstet- 
rics and  Gynecology  on  the  University  Division 
of  the  Minneapolis  City  Hospital,  and  Dr.  Pot- 
ter, the  pathologist  and  bacteriologist  of  that 
institution,  who  have  extended  the  greatest 
courtesies  in  my  service  and  made  it  possible 
for  me  to  use  in  mv  work  all  clinical  material 


10  PEEFACE 

and  records  and  all  the  most  advanced  labora- 
tory aids  that  such  a  competent  laboratory  staff 
and  well  appointed  hospital  can  offer. 

To  Dr.  J.  Warren  Bell  for  care  in  pernsing 
the  manuscript  and  for  his  helpful  criticisms. 

All  opinions  expressed  are  the  result  of  my 
personal  studies,  experiences,  and  judgment  to 
date,  and  I  alone  stand  sponsor  for  them. 

E.  T.  LaVake. 

Minneapolis,   Minn. 


CONTENTS 


CHAPTER  I 
Sepsis .17 

CHAPTER  II 
Toxemias    of    Pregnancy 41 

CHAPTER  III 
Hemorrhage   in    Obstetrics 74 

CHAPTER  IV 
Heart  Lesions  and  Tuberculosis 108 

CHAPTER  V 
Forceps        112 

CHAPTER  VI 
PoDALic    Version 122 

CHAPTER  VII 
Prolapse  of  the  Cord 126 

CHAPTER  VIII 
Breech    Delivery 129 

CHAPTER  IX 
Delivery   of   Twins 132 

CHAPTER  X 
C^.SAREAN      Section 134 

CHAPTER  XI 
Occiput  Posterior  Positions 140 

11 


12  COITTENTS 

CHAPTER  XII 
Face    Presentation 144 

CHAPTER  XIII 
Brow   Presentation 146 

CHAPTER  XIV 
Rules  in  Obstetrics 149 


FOREWORD 


The  aim  of  this  book  is  to  group  the  material 
of  obstetrics  so  that  the  field  may  lie  before 
the  student  as  a  picture,  having  in  the  fore- 
ground the  most  important  problems  and 
grouped  in  the  background  the  lesser  problems 
arranged  according  to  their  relative  impor- 
tance. Thus  it  may  stand  as  a  frontispiece  to 
the  study  of  obstetrics  in  much  the  same  man- 
ner as  do  some  of  the  frontispieces  to  Dickens' 
works  in  which  subsidiary  characters  and 
scenes  are  grouped  around  the  central  themes 
recalling  to  mind  at  a  glance  the  basic  actions 
of  the  work. 

Thackeray,  in  the  prefatory  lines  to  his  in- 
imitable ^^Book  of  Snobs''  remarks  that  ^Svhen 
men  commence  an  undertaking  they  are  pre- 
pared to  show  that  the  absolute  necessities  of 
the  world  demand  its  completion."  I  do  not 
wish  to  furnish  an  example  of  the  humor  of 
this  remark. 

Familiarity  with  the  standard  textbooks  by 
Berkeley  and  Bonney,  Bumm,  Cragin,  Davis, 
DeLee,  Edgar,  Hirst,  Jewett,  Peterson,  Wil- 
liams, and  others,  makes  it  quite  apparent  that 

13 


14  FOKEWOED 

additional  encyclopedic  textbooks  mil  not  be 
an  absolute  necessity  for  a  few  years  at  least. 
However,  after  the  necessary  study  of  such 
books,  the  student  is  likely  to  come  away  with 
a  picture  of  obstetrics  made  up  of  the  anatomy, 
physiology  and  pathology  of  pregnancy,  labor 
and  puerperium,  together  vntla.  operative  tech- 
nic,  laid  out  according  to  order  of  exposition 
rather  than  according  to  frequency  of  occur- 
rence and  importance  of  incidence  and  sequelse. 
The  more  startling  conditions  and  procedures 
are  more  likely  to  impress  themselves  upon  the 
memory  than  are  the  final  results.  This  book 
attempts  to  correct  this  frequent  lack  of  per- 
spective on  the  part  of  the  student. 

These  talks  are  merely  printed  chats  similar 
to  those  often  held  with  students  during  the 
hours  of  waiting  while  on  out-patient  cases. 
They  have  taken  form  from  observations  of  my 
own  experiences,  especially  my  mistakes,  and 
those  of  others,  called  to  my  attention  in  the 
course  of  out-jjatient  and  hospital  clinics  and  in 
private  practice.  The  conclusions  reached  and 
stated  are  purely  personal  and  regarded  by  me 
as  such  only  They  have  proved  of  value  to  me 
and  may  aid  those  not  giving  their  entire  at- 
tention to  this  branch  of  practice. 


INTRODUCTION 


A  book  which  is  designed  to  be  neither  a  text- 
book nor  a  compend  is  unique. 

Dr.  LaVake  in  this  little  volume  has  stuck  to 
his  text  and  has  done  what  he  set  out  to  do ;  to 
emphasize  some  of  the  commoner  complications 
of  obstetrics  arranged  in  the  order  of  their  im- 
portance and  presented  in  a  familiar  ** chatty" 
way. 

He  has  not  tried  to  tell  all  about  even  the 
subjects  treated;  but  in  a  few  *' talks,"  has  at- 
tempted to  give  a  perspective  that  will  help  to 
establish  the  relative  importance  of  certain 
problems.  He  has  entertainingly  presented 
some  very  important  facts  which  are  necessary 
to  the  successful  practice  of  obstetrics. 

Here  is  a  book  which  sets  in  relief  important 
facts,  establishes  relative  values,  and  will  stim- 
ulate the  reader  to  further  study  and  more  care- 
ful obstetrics. 

J.  C.  LiTZENBERG,  M.D. 


15 


TALKS  ON  OBSTETRICS 


CHAPTER  I 
SEPSIS 

The  prevention  of  sepsis  is  by  far  the  most 
important  problem  in  obstetrics.  General  mor- 
tality statistics  show  that  sepsis  kills  almost 
as  many  parturient  women  as  do  all  other 
causes  put  together.  In  the  United  States 
alone  it  may  be  computed  that  approximately 
seven  thousand  five  hundred  women  die  an- 
nually from  this  dread  complication,  and  that 
severe  sepsis  arises  in  about  one  in  every  hun- 
dred parturient  women  on  an  average  through- 
out the  country.  The  incidence  of  mild  sepsis 
would  be  far  in  excess  of  the  latter  figure.  Let 
it  not  be  thought  that  this  tremendous  toll  can 
be  accounted  for  by  the  immense  number  of 
cases  imperatively  demanding  obstetric  opera- 
tions and  other  interferences.  This  is  clearly 
shown  by  the  fact  that  in  maternity  hospitals, 
where  the  number  of  abnormal  cases  demand- 
ing interference  would  naturally  be  above  the 

17 


18  TALKS   ON   OBSTETRICS 

average  found  in  general  practice,  the  incidence 
of  sepsis  is  approximately  one  in  two  hundred 
cases.  The  clear  conclusions  to  be  drawn  are 
that  either  the  average  aseptic  technic  is  poor 
or  that  meddlesome  interference  is  rife. 

The  beginner  nearly  always  pictures  the 
patient  as  dying  from  exhaustion  due  to  mal- 
position of  the  passenger,  obstruction  in  the 
passage,  lack  of  propulsive  forces,  hemorrhage, 
etc.,  and  in  his  worry  and  impatience  is  inclined 
to  unnecessary  interference,  failing  to  see  the 
dread  specter,  sepsis,  at  his  elbow.  There  will 
always  be  a  small  mortality  rate  attendant  upon 
the  accidents  of  childbirth,  a  tragedy  in  every 
case,  but  nothing  can  equal  the  tragedy  of  death 
by  sepsis  in  what  should  otherwise  have  been 
a  normal  case.  The  prevention  of  such  a  catas- 
trophe should  be  foremost  in  the  mind  of  every 
physician  in  the  conduct  of  every  case.  We 
should  remember  that  Nature  has  had  to  deal 
with  sepsis  from  time  immemorial  and  has  so 
provided  against  it  from  an  anatomic  stand- 
point that  without  interference  this  complica- 
tion is  almost  inconceivable.  From  an  evolu- 
tionary standpoint  Nature  has  seemingly  or- 
dained that  it  were  better  for  the  future  of 
the  race  that  all  women  with  marked  deform- 
ities should  die  without  propagating  their  kind 


SEPSIS  19 

than  that  normal  women  should  die  of  sepsis. 
Modern  obstetric  methods  should  make  it  pos- 
sible to  save  the  great  majority  of  deformed 
women  and  their  offspring  without  prejudicing 
the  lives  of  the  normal  women. 

Malpositions  and  obstructions  are  not  com- 
mon, neither  are  the  mortal  accidents  of  labor 
as  compared  to  the  incidence  of  infection.  The 
history,  signs  and  symptoms  of  the  patient, 
together  with  perfection  in  pelvimetry  and  ab- 
dominal and  rectal  examinations  make  the  pres- 
ence of  such  abnormal  conditions  possible  of 
determination  with  almost  perfect  accuracy 
without  infringing  upon  Nature's  guards 
against  infection.  Let  sepsis  be  the  specter  and 
not  the  advent  of  other  untoward  conditions  in 
which,  if  suspected,  time  is  generally  ample  in 
which  to  get  the  advice  of  others  before  at- 
tempting to  aid  Nature  and  possibly  doing 
irreparable  damage  where  Nature  might  other- 
wise have  consummated  delivery  without  un- 
toward or  fatal  results  to  child,  mother,  or  both. 

Death  is  not  the  only  danger  in  sepsis.  Many 
women  recover  only  to  be  potential  invalids 
for  life.  We  may  postulate  from  statistics  that 
for  every  woman  dying  of  severe  sepsis  three 
recover.  A  case  coming  under  my  observation 
recently   will    illustrate    what    recovery   may 


20  TALKS   ON   OBSTETRICS 

mean.  This  woman,  eight  years  ago,  after  a 
very  easy  and  normal  labor  in  which,  however, 
vaginal  examinations  were  freely  made,  de- 
veloped a  sepsis  which  kept  her  bedridden  for 
thirteen  months.  The  left  hip  became  involved 
in  a  nontnberculous,  septic  process  which  re- 
sulted in  a  permanently  stiff  hip  with  the  thigh 
adducted  to  snch  a  degree  that  in  the  second 
pregnancy  the  question  arose  as  to  whether  it 
would  obstruct  the  birth  of  the  child.  Throm- 
bosis of  the  external  iliac  vessel  on  the  left 
side  resulted  in  a  practically  useless  limb  which 
for  the  last  seven  years  would  break  down  in 
ulceration  at  any  point  after  pressure  or  slight 
injury.  She  had  been  correctly  advised  to  have 
this  leg  amputated,  but  had  not  as  yet  followed 
the  advice.  After  seven  years  of  dragging 
around  on  crutches  the  patient  presented  her- 
self five  months  pregnant,  with  a  stiff  adducted 
useless  limb,  a  severe  lumbar  compensatory  sco- 
liosis, and  a  terrible  dread  of  the  coming  labor. 
During  all  these  years  she  had  been  practically 
incapacitated  for  household  duties,  a  great  suf- 
ferer and  a  source  of  infinite  anxiety  to  her 
family.  The  family  was  not  wealthy  and  the 
fact  that  her  former  illness  had  cost  the  family 
over  three  thousand  dollars  for  which  they  had 
had  to  run  in  debt,  added  to  her  worry.    This  is 


SEPSIS  21 

only  one  example  of  so-called  recovery  from 
sepsis.  Cases  of  chronic  invalidism  resulting 
from  pathologic  processes  in  the  pelvis,  endo- 
cardium and  kidneys  following  sepsis  are  not 
infrequent. 

The  case  just  cited  is  of  so  much  interest, 
especially  from  the  standpoint  of  the  value  of 
external  examinations  and  the  danger  of  rou- 
tine vaginal  examinations  in  labor,  that  I  will 
give  the  history  of  her  second  pregnancy  and 
labor.  She  presented  herself  in  the  fifth  month 
of  gestation.  At  that  time,  careful  pelvimetry 
and  internal  pelvic  examination,  together  with 
a  good  skiagraph  of  the  pelvis,  gave  no  signs 
of  obstructive  deformity.  During  the  seventh 
and  eighth  months  she  suffered  from  a  severe 
pyelonephritis  of  the  right  kidney,  with  large 
quantities  of  pus  in  the  urine  and  chills  and 
rise  of  temperature  two  or  three  times  a  week. 
Under  hexamethylenamin  and  copious  intake 
of  water  this  improved  greatly  in  the  last  month 
of  pregnancy.  One  week  before  labor  she  had 
an  acute  otitis  media  and  the  ear  was  discharg- 
ing at  the  time  of  labor.  For  one  month  before 
labor  and  all  during  labor  no  vaginal  examina- 
tions were  made.  Eectal  and  abdominal  exami- 
nations showed  a  vertex  presentation  and  an  0. 
L.  A.  position.    Very  short  normal  labor  and 


22  TALKS    ON    OBSTETRICS 

normal  puerpermm.  In  this  case,  in  the  pres- 
ence of  a  pyelonephritis,  vaginal  examinations 
would  have  been  especially  dangerous.  Vaginal 
examinations  are  dangerous  in  all  cases,  in  most 
cases  unnecessary  and  an  example  of  meddle- 
some interference. 

How  may  we  reduce  to  a  minimum  the  in- 
cidence of  sepsis  ? 

At  the  present  time  four  great  factors  may 
militate  against  the  prevention  of  sepsis : 

1.  Failure  of  the  public  to  realize  the  neces- 
sity of  special  surroundings  and  care  for  the 
parturient  woman. 

2.  Failure  of  attendants  in  not  giving  explicit 
directions  to  pregnant  women. 

3.  Poor  technic  and  meddlesome  interference 
on  the  part  of  attendants. 

4.  Poor  technic  on  the  part  of  nurses. 

It  should  be  our  aim  to  combat  these  four 
causes  of  sepsis. 

Let  us  try  by  every  means  to  impress  upon 
the  public  the  necessity  of  procuring  for  the 
parturient  woman  as  ideal  surroundings  as  the 
public  now  demands  for  other  surgical  cases. 
This  is  being  attempted  in  lay  journals, 
women's  clubs  and  by  verbal  and  written  in- 
structions of  physicians  to  their  patients.    It 


SEPSIS  23 

has  been  my  personal  practice  to  give  to  each 
woman  coming  under  my  care  a  booklet  urging 
the  best  surroundings.  It  has  been  my  expe- 
rience that  most  women,  from  unscientific  hear- 
say, are  imbued  with  unnecessary  dread  rather 
than  by  the  saving  fear  which  should  inspire 
them  to  procure  an  accurate  knowledge  of  safe- 
guards in  pregnancy  and  labor.  Written  in- 
formation and  instructions  remove  this  depress- 
ing dread  and  in  the  large  majority  of  instances 
gain  the  earnest  cooperation  of  the  patient  and 
her  family. 

Physicians  are  asked  daily  as  to  the  relative 
safety  of  the  home  and  the  hospital  in  labor. 
It  should  go  without  saying  that  this  decision 
should  be  rendered  entirely  with  regard  for 
the  safety  of  the  mother  and  child  and 
not  for  the  benefit  to  the  physician.  No 
physician  with  an  accurate  knowledge  of  bac- 
teriology, modes  of  infection  and  technic  of 
operative  procedures  will  gainsay  that  a  hos- 
pital especially  equipped  and  making  provision 
for  the  immediate  isolation  of  infected  cases 
and  attended  by  those  not  coming  in  contact 
with  infectious  diseases,  is  the  place  of  greatest 
safety  for  the  woman  in  labor.  It  is  obvious 
that  if  the  physical  conditions  of  the  hospitals 
are  such  that  direct  or  indirect  communication 


24  TALKS   OIT   OBSTETRICS 

can  exist  between  normal  obstetric  cases  and 
infected  cases,  medical  or  surgical,  the  home, 
properly  equipped,  is  the  safer  environment. 
The  abnormal  cases  should  all  have  ideal  hos- 
pital surroundings.  At  the  present  time  it  is 
apparent  that  we  must  weigh  the  dangers  on 
both  sides  and  decide  each  case  individually 
according  to  the  possibilities  of  home  and  hos- 
pital conditions  and  the  degree  of  normality 
of  the  case. 

Many  women  likely  become  infected  because 
of  the  lack  of  explicit  instructions  regarding 
the  birth  canal.  In  proof  of  this  fact  I  would  re- 
call two  normal  labors  followed  by  an  almost 
fatal  sepsis.  In  these  cases  no  vaginal  exanii- 
nations,  instrumentations  or  stitches  were  used 
upon  which  the  blame  might  be  placed.  One 
admitted  intercourse  during  labor  and  the  other 
gave  notice  of  the  accession  of  labor  by  tele- 
phoning that  she  considered  the  birth  imminent 
because  she  could  feel  the  child's  head.  This 
woman  had  been  making  frequent  vaginal  ex- 
aminations upon  herself.  The  intelligence  and 
station  of  both  these  women  speak  for  the  ne- 
cessity of  explicit  directions. 

It  is  our  duty  to  act  as  sanitary  engineers 
and  as  far  as  we  are  able  rid  the  immediate  en- 
vironment of  the  birth  canal  of  foci  of  infection. 


SEPSIS  25 

We  should  also  aim  to  discover  all  remote  foci 
of  infection  in  the  patient  and  eradicate  them  if 
possible  or  plausible.  Especially  is  this  perti- 
nent to  the  oral  cavity,  which  in  some  patients 
is  as  dangerous  and  inimical  to  their  safety  as 
are  discharging  ears,  empyemas  and  what  not. 
Concerning  the  danger  of  systematic  infection 
through  the  mouth  and  the  important  relation 
of  the  care  of  the  teeth  to  the  general  health, 
we  will  discuss  subsequently  at  greater  length. 
The  patient  should  have  definite  instructions 
as  regards  bathing.  Tub  baths  up  to  the  ninth 
month  and  then  spray  baths.  Why  not  tub 
baths  in  the  last  month?  We  know  that  the 
normal  bacterial  content  of  the  vagina  and  its 
acid  media  are  inimical  to  pyogenic  bacteria. 
If  pyogenic  bacteria  do  gain  access  and  survive, 
the  natural  drainage  flow  of  the  secretions  from 
within  outward  tends  to  render  the  upper 
vagina  less  infested  than  the  lower  vagina.  To 
say  that  nothing  should  enter  the  vagina  dur- 
ing the  last  month  is  merely  setting  an 
arbitrary  period  during  which  time  Nature 
may  render  the  vagina  as  aseptic  as  possible. 
The  tub  bath  is  surely  capable  of  floating  organ- 
isms from  without  in,  or  of  carrying  organisms 
from  the  lower  to  the  upper  part  of  the  vagina, 
especially  when  the  perineum  is  relaxed  from 


26  TALKS   ON   OBSTETRICS 

former  labors  and  the  introitus  is  patulous. 
Before  removing  a  piece  of  bone  from  a  severe 
comminuted  compound  fracture  we  surely 
would  not  prepare  the  patient  by  giving  a  tub 
bath.  This  is  clearly  an  exaggerated  simile 
and  yet  the  principle  is  the  same.  The  man 
who  treats  the  birth  canal  as  he  would  an  un- 
infected compound  fracture  is  playing  safe 
with  infection. 

A  frequent  question  from  patients  is  whether 
or  not  they  should  take  douches.  I  believe  that 
the  danger  of  introducing  infection  with  the 
douche  as  given  by  the  patient  overbalances 
its  possible  efficacy  in  washing  out  or  killing 
bacteria.  It  may  wash  the  bacteria  up  into 
the  cervical  canal,  and  therefore  it  is  safer  to 
advise  the  patient  not  to  use  douches  in  the  last 
month,  because  of  the  danger  of  infection. 

Patients  should  be  advised  to  wear  closed 
underclothes  during  the  last  months  of  preg- 
nancy to  protect  the  vulva  from  dust  and  as  the 
pressure  on  the  bladder  during  the  last  months 
compels  more  frequent  urination,  it  is  well  for 
them  to  carry  clean  paper  covers  for  the  toilet 
seats  which  they  may  have  to  use. 

In  taking  all  these  precautions  we  are  doing 
nothing  more  than  a  sanitary  engineer  would 


SEPSIS  27 

do  in  protecting  an  area  from  possible  con- 
tamination. 

To  all  well-trained  physicians  the  necessity 
of  aseptic  technic  is  clearly  manifest,  but  to 
many  it  does  not  seem  so  clear  that  the  anat- 
omy of  the  vulva  together  mth  its  close 
proximity  to  the  anus  diminishes  the  pos- 
sibility of  perfect  asepsis.  This  should  ever  be 
kept  in  mind  in  relation  to  the  dangers  attend- 
ant upon  vaginal  examinations,  manipulations 
and  instrumentations. 

It  may  suggest  itself  that  the  reason  why  so 
many  women  suffer  and  die  of  sepsis  is  that 
many  are  attended  by  people  who  are  not  phy- 
sicians. Undoubtedly  this  fact  may  account 
for  many  fatalities.  We  must  depend  upon  the 
education  of  the  public  for  the  abolishment  of 
this  cause.  It  cannot  be  gainsaid,  however,  that 
sepsis  often  follows  the  physician,  so  let  us 
confine  our  attention  in  this  discussion  to  our- 
selves. As  mentioned  once  before,  if  every 
careful  and  well  trained  obstetrician  will 
review  his  cases  and  recall  even  the  large 
number  requiring  imperative  interference  in 
which  no  sepsis  resulted,  in  the  face  of  the 
average  frequency  of  sepsis,  the  deductions  can 
only  be  that  either  the  average  aseptic  technic 
is  poor  or  that  meddlesome  interference  is  rife. 


28  TALKS   OTT   OBSTETRICS 

Both  deductions,  I  believe,  are  correct,  but  I 
believe  we  err  in  not  laying  greater  emphasis 
upon  the  danger  of  meddlesome  interference. 

I  am  convinced  that  we  would  lower  markedly 
the  incidence  of  infection  by  universally  dis- 
continuing the  routine  vaginal  examination  in 
labor  and  substituting  the  rectal  examination. 
Needless  to  say,  upon  the  technic  would  depend 
the  frequency  of  infection  f ollomng  the  vaginal 
examination,  but  even  with  the  best  surround- 
ings, the  most  careful  men  and  the  best  technic, 
no  doubt  we  have  all  seen  sepsis  develop  where 
vaginal  examinations  alone  could  be  blamed. 
That  the  seriousness  of  tliis  procedure  is  well 
knoT\m  is  evidenced  by  the  fact  that  even  in 
those  hospitals  and  clinics,  throughout  the 
country,  where  the  routine  vaginal  examina- 
tions are  taught  and  used,  each  examination 
is  charted  in  order  not  only  to  follow  the  prog- 
ress of  the  case,  but  in  order  to  partially  place 
responsibility  if  sepsis  ensues.  The  routine 
vaginal  examination  is  wrong  and  no  amount  of 
charting  can  make  it  right.  If  infection  en- 
sues, nurses  are  often  blamed.  This  is  often 
a  specious  and  unjust  judgment.  If  the  patient 
has  followed  our  instructions  that  nothing 
should  enter  the  vagina  during  the  last  month 
of  pregnancy,  together  with  our  other  protec- 


SEPSIS  29 

tive  instructions,  and  we  have  followed  the  in- 
structions ourselves  and  permitted  no  vaginal 
manipulations  during  the  month  before,  dur- 
ing or  just  subsequent  to  labor,  and  no  gon- 
orrheal infection  obtains,  then  and  then  only 
may  we  turn  to  the  nurses  for  an  explanation, 
in  the  advent  of  sepsis  in  the  normal  case  of 
labor. 

It  is  perfectly  surprising  what  niceties  of 
diagnosis  the  rectal  examination  allows.  Prog- 
ress of  labor,  dilatation  of  the  cervix,  presen- 
tation, position,  prolapsed  cord,  and  often  pla- 
centa previa,  can  be  diagnosed  with  accuracy. 
When  the  examination  is  completed,  subsequent 
imperative  operations  such  as  Csesarean  sec- 
tion, forceps,  etc.,  may  be  instituted  without 
the  danger  of  a  previously  introduced  infection. 
The  examinations  may  be  repeated  and  the 
progress  of  labor  followed  accurately,  and  al- 
ways with  the  same  freedom  from  the  danger 
of  infection.  This  applies  not  to  the  few,  but 
to  every  one  of  us  even  under  the  Avorst  possible 
conditions.  If  obscurity  still  holds  after  care- 
fully combined  rectal  and  abdominal  examina- 
tions, which  may  occur  in  exceptional  cases, 
we  still  have  the  vaginal  examination  to  fall 
back  upon  and  can  enter  into  the  elaborate 
technic  that  its  danger  warrants.    In  this  con- 


30  TALKS   ON    OBSTETRICS 

nection  let  me  say  that  careful  abdominal  ex- 
aminations are  too  often  neglected.  I  believe 
that  the  general  use  of  the  routine  rectal  ex- 
amination instead  of  the  routine  vaginal  ex- 
amination, for  diagnostic  purposes  in  labor, 
would  reduce  the  incidence  of  infection  to  as 
great  an  extent  as  did  the  introduction  of  the 
use  of  sterile  rubber  gloves  in  the  vaginal  ex- 
amination and  labor.  In  the  rectal  examination 
it  is  hardly  necessary  to  emphasize  the  use  of 
rubber  gloves  to  prevent  contamination  of  the 
hand,  which  would  militate  against  asepsis  in 
the  subsequent  scrubbing  up  for  the  use  of  the 
sterile  delivery  gloves. 

It  is  not  necessary  to  mention  all  the  errors 
of  judgment  in  respect  to  interference  in  labor 
with  consequent  liability  to  sepsis,  but  in  the 
face  of  histories  of  cases  and  physical  findings, 
it  would  be  neglect  not  to  emphasize  that  most 
prolific  source  of  sepsis,  invalidism  and  prepa- 
ration for  subsequent  surgical  operations; 
namely,  the  indiscriminate  use  of  forceps.  This 
is  such  an  important  subject  that  I  wish  to 
make  it  the  topic  of  a  separate  talk. 

We  now  come  to  a  consideration  of  a  most 
potent  factor  in  the  prevention  of  sepsis; 
namely,  scientific  nursing.  Obstetric  nurses 
should  be  especially  well  trained  in  bacteriology 


SEPSIS  31 

and  the  basic  principles  of  asepsis.  In  no  other 
surgical  branch  of  nursing  is  this  knowledge  of 
more  importance.  This  is  most  apparent  when 
we  consider  the  postpartum  nursing.  The  day 
will  come  when  we  will  have  only  special  nurses 
for  this  branch  of  surgery.  Considering  the 
intimate  contact  of  the  nurse  with  the  patient 
from  the  beginning  of  labor  to  the  end  of  all 
danger  in  the  puerperium  it  is  especially  es- 
sential that  she  realize  the  danger  of  coming 
from  an  infectious  case  to  a  case  of  labor.  She 
should  realize  that  whereas  the  patient  is  at 
least  partially  immune  to  the  bacteria  in  her 
usual  environment,  she  may  quickly  succumb  to 
virulent  bacteria  foreign  to  her  environment. 
Considering  the  long  and  intimate  contact  of 
the  nurse  and  the  patient,  it  is  even  more 
dangerous  for  a  nurse  to  come  from  an  infec- 
tious case  than  for  a  physician,  although  both 
should  be  equally  deprecated.  Be  sure  to  in- 
quire about  this  in  regard  to  each  nurse.  I  have 
several  times  had  the  experience  of  finding  that 
a  nurse,  a  friend  of  the  family  and  engaged 
for  the  case  months  beforehand,  not  wanting 
to  disappoint  the  patient,  would  come  to  the 
case  directly  from  a  case  of  tonsillitis  or  what 
not,  even  leaving  the  case  she  was  on  from  a 
mistaken  sense  of  duty.    Some  of  these  cases 


32  TALKS    ON   OBSTETRICS 

have  had  to  be  delivered  by  instnimentation 
followed  by  extensive  repair.  Imagine  the  dan- 
ger to  which  we  would  subject  such  a  patient 
if  we  allowed  this  nurse  to  prepare  the  patient, 
assist  in  the  delivery,  and  follow  up  the  after- 
treatment.  This  danger  may  be  reduced  by 
early  instructing  patients  that  their  surround- 
ings in  labor  are  essential  to  their  safety  and 
in:  particular  that  their  nurse  should  be  one 
having  had  special  training  and  not  having 
come  from  an  infectious  case.  Only  under 
these  two  conditions  will  a  nurse  who  is  a  friend 
of  the  family  be  acceptable.  This  militates 
against  the  oldest  living  female  member  of 
the  family  who  in  the  past  has  so  frequently 
been  entrusted  mth  the  duty  of  assisting  the 
physician.  In  the  majority  of  cases  it  assures 
the  earnest  cooperation  of  the  patient  and  her 
family  in  obtaining  the  best  surroundings  and 
assistants. 

Special  instructions  should  be  given  to  nurses 
to  preclude  certain  slips  in  technic  which  may 
be  encountered.  When  a  patient  comes  in  labor 
she  should  have  a  spray  or  sponge  bath  and 
not  a  tub  bath.  The  nurse  should  see  that  she 
empties  her  bladder,  should  give  her  an  enema, 
and  then  prepare  the  vulva  by  shaving  or 
clipping,  followed  by  cleansing  and  an  exter- 


SEPSIS  33 

nal  sterile  douche,  after  wliich  preparation  a 
sterile  vulva  pad  should  be  applied  and  held 
in  place  by  a  T-binder.  "Where  the  ster- 
ile pad  has  not  been  held  on  in  this  manner, 
1  have  often  seen  it  drop  on  the  floor  or 
elsewhere  and  have  seen  the  patient  pick  it  up 
and  put  it  in  place  again.  The  patient  should 
be  definitely  told  by  the  nurse  not  to  touch  the 
vulva  throughout  labor.  We  will  not  go  into 
general  nursing  technic,  but  one  other  point 
does  need  emphasizing,  however,  and  that  is 
that  you  acquaint  yourself  with  the  technic  of 
the  hospital  to  which  you  may  send  your  case. 
See  that  no  inexperienced  nurses  are  allowed 
to  change  the  vulvar  pads  in  the  puerperium. 
The  changing  of  the  vulvar  pads  and  the  care 
of  the  patient  after  urination  and  defecation 
approach  in  seriousness  a  major  surgical  dress- 
ing. Women  have  often  brought  to  my  atten- 
tion the  differences  of  technic  used  by  nurses 
and  the  technic  of  certain  unskilled  nurses  has 
been  such  a  source  of  worry  to  them  that  they 
have  expressed  a  dread  at  not  having  their 
regular  nurse  attend  them.  In  histories  of 
otherwise  normal  labors  many  patients  have 
stated  their  opinion  that  the  accession  of  a 
**milk  leg"  was  due  to  carelessness  in  nursing. 


34  TALKS   ON   OBSTETKICS 

We  cannot  be  too  careful  in  seeking  to  elim- 
inate this  possible  factor. 

In  carefully  watching  the  tendencies  of  stu- 
dents and  others  in  their  handling  of  a  delivery, 
three  errors  stand  out  conspicuously  as  tend- 
ing to  increase  the  possible  incidence  of  sepsis. 

1.  Lack  of  care  in  carrying  out  the  most  rigid 
aseptic  technic  that  textbooks  and  good  clinics 
teach  and  a  tendency  to  place  too  much  con- 
fidence in  antisepsis.  (After  a  clear  contami- 
nation a  man  mil  smsh  his  gloved  hand  around 
in  an  antiseptic  solution  and  proceed  with  per- 
fect confidence.) 

2.  Not  appreciating  the  fact  that  the  average 
normal  first  labor  lasts  eighteen  hours  and  sub- 
sequent labors  from  twelve  to  fourteen  hours. 
In  consequence  they  are  apt  to  become  over- 
anxious after  a  few  hours,  especially  when  deal- 
ing with  hypersensitive  women  and  under  the 
importunities  of  anxious  relatives  and  friends, 
think  that  something  must  be  wrong  even  when 
they  feel  sure  that  their  abdominal  and  rectal 
examinations  show  that  ever3i:hing  is  normal, 
and  as  a  result  they  are  led  to  make  many  vag- 
inal examinations  and  are  too  prone  to  think 
that  operative  delivery  will  be  necessary. 

3.  They  forget  the  basic  fact  that  the  slow 
noninstrumental   delivery   tends   to   limit   the 


SEPSIS  35 

number  of  lacerations  and  that  every  lacera- 
tion means  an  extra  channel  for  the  possible 
entrace  of  infection. 

The  mention  of  lacerations  brings  to  mind 
a  stage  in  labor  at  which  point  infection  is  easily 
introduced.  In  watching  the  conduct  of  some 
labors  you  will  notice  that  men,  in  the  last  part 
of  the  second  stage,  will  soil  the  right  hand  by 
coming  in  contact  with  the  anus,  in  the  endeavor 
to  protect  the  perineum  when  the  head  and 
shoulders  are  passing  over  it.  After  the  birth 
of  the  baby  they  will  then  rinse  off  the  hand 
in  some  antiseptic  solution  and  proceed  to  make 
vaginal  examinations  in  the  search  for  cervical 
or  perineal  lacerations.  "Why  more  women  are 
not  infected  after  this  maneuver  is  hard  to  ex- 
plain. It  suggests  a  corroboration  of  St. 
Ansehn's  treatise,  **  Truly  there  is  a  God,  al- 
though the  fool  hath  said  in  his  heart.  There  is 
no  God."  Cervical  tears  should  be  left  alone 
unless  imperative  demand  for  repair  is  made 
by  severe  hemorrhage  and  most  perineal  tears 
can  be  recognized  without  entering  the  vagina. 
Keep  out  of  the  vagina  if  possible,  and  if 
entrance  is  imperative,  change  to  a  clean 
glove  and  do  not  rely  on  the  antiseptic  value 
of  a  rapid  immersion  in  any  antiseptic  solution. 
No  gynecologist  would  think  of  doing  otherwise 


36  TALKS   ON   OBSTETRICS 

in  operating  for  secondary  repair  of  the  peri- 
neum. After  suturing  the  perineum  we  can 
test  the  competency  of  the  perineum  as  well  by 
rectal  examination  as  by  vaginal  examination. 

We  should  all  aim  to  correct  these  tendencies 
as  they  exist  in  ourselves.  No  subject  in  ob- 
stetrics warrants  more  attention  and  detailed 
care  than  this  subject  of  asepsis.  By  taking 
thought  we  may  not  be  able  to  add  a  cubit  to 
our  stature,  but  by  taking  thought  in  obstetrics 
we  may  greatly  reduce  the  occurrence  of  sepsis, 
that  dread  specter  that  stands  at  our  elbow 
in  every  case,  normal  and  abnormal. 

If  all  prophylactic  measures  have  proved  of 
no  avail,  the  next  great  problem  for  the  exer- 
cise of  judgment  is  the  treatment  of  sepsis. 

Here  let  us  remember  that  as  Nature's 
safeguards  are  the  best  in  the  prevention  of 
sepsis,  so  is  her  treatment.  Give  Nature  a 
chance  undisturbed  and  she  will  bring  about 
better  results  than  will  rapid  interference  on 
our  part.  Let  hemorrhage  and  drainage  be  the 
only  indications  for  interference.  It  is  part  of 
the  technic  of  every  labor  to  examine  the  mem- 
branes and  placenta  carefully  to  see  that  large 
masses  have  not  been  retained  to  obstruct 
drainage.  If  masses  have  been  retained,  let 
the  fact  set  us  on  our  guard,  but  do  not  attempt 


SEPSIS  37 

to  remove  them  unless  hemorrhage  or  blocking 
of  the  cervical  canal  with  lack  of  drainage 
makes  it  imperative.  In  most  cases  they  will 
come  away  by  themselves  in  a  few  days  and  we 
have  not  then  imposed  the  added  danger  of  the 
possible  introduction  of  infection.  Do  not  give 
donches  which  may  spread  any  existing  infec- 
tive material  to  regions  othermse  normal.  If 
masses  have  been  retained  and  subsequent  hem- 
orrhage or  marked  closing  of  the  cervix  with 
symptoms  render  it  imperative  to  act,  with  the 
greatest  aseptic  care  remove  the  same  with  the 
gloved  finger  or  with  a  large  dull  curette  see- 
ing to  it  that  this  procedure  disturbs  as  little 
as  possible  the  leucocytic  barrier  that  Nature 
has  undoubtedly  thrown  around  any  iufective 
focus  present.  In  the  great  majority  of  cases 
no  interference  will  be  found  necessary. 

Each  and  every  one  of  the  follomng  general 
therapeutic  measures  is  important  as  an  aid  to 
Nature  in  effecting  a  cure: 

1.  Placing  the  patient  in  the  Fowler  or  semi- 
sitting posture,  to  promote  uterine  drainage. 

2.  The  administration  of  fluid  extract  of  er- 
got, one  dram  three  times  a  day,  to  contract  the 
uterus  and  close  the  sinuses  against  infection, 
always  keeping  in  mind,  however,  that  too  much 


38  TALKS   ON   OBSTETRICS 

ergot  may  close  the  cervix  and  interfere  with 
drainage. 

3.  Due  attention  to  the  bowels  and  plenty  of 
water  to  flush  out  the  system  by  all  the  chan- 
nels of  elimination. 

4.  Forced  feeding  with  easily  assimilable 
nourishing  food  with  the  addition  of  brandy  or 
whisky,  the  latter  acting  both  as  a  food  of  high 
caloric  value  and  as  a  stimulant. 

5.  Treatment  in  the  fresh  air  and  sunlight. 

If  the  process  localizes,  do  not  incise  until 
definite  fluctuation  obtains.  If  the  patients  are 
to  recover  at  all  at  least  three  out  of  every  four 
cases  presenting  marked  areas  of  induration 
will  clear  up  without  pus  formation.  It  is  a 
common  tendency  to  want  to  resort  to  incision 
too  quickly  in  the  presence  of  induration.  I 
have  again  and  again  seen  areas  of  induration 
incised  without  obtaining  pus,  with  a  resulting 
healing  of  the  incision  and  with  a  final  breaking 
down  and  fluctuation  at  a  point  far  distant,  the 
incision  of  this  fluctuating  mass  resulting  in 
proper  drainage  and  a  cure.  Too  early  incision 
may  only  spread  the  infection.  Without  fluc- 
tuation let  the  process  alone  and  depend  solely 
on  general  supportive  measures  as  outlined 
above. 

It  is  well  for  every  man  to  view  a  puerperal 


SEPSIS  39 

rise  of  temperature  as  an  infection  and  not 
set  stock  on  nervous  causes.  A  frequent  mis- 
take, however,  is  to  become  panic  stricken  and 
think  of  immediate  interference  before  one  has 
satisfied  himself  by  a  thorough  physical  and 
laboratory  examination  that  puerperal  infec- 
tion is  alone  the  cause  of  the  rise  of  tempera- 
ture. If  puerperal  infection  is  the  cause,  let 
hemorrhage  and  lack  of  drainage  be  the  only 
indications  for  immediate  manual  interference. 
Whatever  the  cause,  free  catharsis  will  often 
bring  our  anxiety  to  a  sudden  end.  If  after  a 
cathartic  the  temperature  does  not  fall  to  nor- 
mal and  remain  there,  look  upon  the  condition 
as  puerperal  sepsis  and  institute  appropriate 
treatment  until  marked  lesions  elsewhere  make 
it  clear  that  we  are  dealing  with  another  con- 
dition. Even  then  consider  that  this  lesion 
may  be  only  another  complication. 

The  greatest  consolation  that  an  obstetrician 
can  have  in  the  face  of  a  sharp  postpartum 
rise  of  temperature  is  the  knowledge  that  he 
could  see  no  slip  in  the  aseptic  technic,  that 
he  has  made  no  vaginal  examinations,  nor  has 
been  compelled  to  use  any  operative  procedure 
and  that  the  absence  of  perineal  lacerations 
necessitated  no  repair.  I  designate  perineal 
lacerations  to  emphasize  the  belief  that  where- 


40  TALKS   ON   OBSTETRICS 

as  all  perineal  lacerations  should  be  repaired 
immediately,  the  only  indication  for  immediate 
repair  of  the  cervix  should  be  hemorrhage.  The 
latter  belief  is  based  on  three  reasons:  first 
and  foremost,  the  predominance  of  the  risk  of 
sepsis  over  the  amount  of  good  actually  ac- 
complished ;  second,  the  frequent  amazing  nat- 
ural restitution  of  cervices  markedly  damaged; 
and  third,  the  distortion  of  the  cervix  after 
labor  may  lead  us  to  sew  too  much  with  a  result- 
ing permanent  distortion  or  stricture  of  the 
cervical  canal. 

In  going  to  every  case  let  us  remember  that 
sepsis  kills  almost  as  many  women  as  do  all 
the  remaining  complications  of  pregnancy  put 
together.  Measures  for  its  avoidance  should 
run  as  a  warp  throughout  all  the  procedures 
of  obstetrics.  As  such  they  should  be  con- 
sidered in  reference  to  all  subsequent  subjects 
discussed. 


CHAPTER  II 
TOXEMIAS  OF  PREGNANCY 

Pre-Eclamptic  Toxemia  and  Eclampsia. 

Next  to  sepsis  the  toxemia  of  pregnancy  re- 
sulting in  eclampsia  kills  more  women  than 
all  remaining  complications.  General  statis- 
tics show  that  twenty-five  per  cent  of  the  deaths 
in  pregnancy  are  due  to  this  condition,  and  in 
maternity  hospitals  the  percentage  often  runs 
as  high  as  forty  per  cent.  It  is  a  frightful  com- 
plication and  every  woman  should  be  looked 
upon  as  a  possible  eclamptic  and  all  precautions 
taken  right  from  the  start  to  guard  against 
the  condition  or  at  least  to  recognize  its  ap- 
pearance at  the  earliest  possible  moment  in 
order  to  institute  immediate  treatment. 

Zweifel  aptly  called  eclampsia  a  disease  of 
theories  and  we  must  admit  that  today  its  basic 
cause  has  not  been  incontrovertibly  proved. 
With  the  autopsy  findings  in  liver,  kidney,  etc., 
together  with  the  signs  and  symptoms  in  life, 
all  are  familiar.  These  have  given  us  clues  for 
treatment.    Other  clues  to  treatment  have  been 

41 


42  TALKS   ON   OBSTETRICS 

given  by  experimental  evidence  and  the  results 
of  empiric  treatment  founded  upon  theories 
more  or  less  substantiated  by  correlated  facts. 
Every  man  must  establish  in  his  mind  at  least 
a  temporary  theory,  deduced  from  all  known 
observations,  in  order  that  he  may  have  some 
foundation  upon  which  to  base  his  prophylaxis 
and  treatment. 

Upon  my  present  belief  in  the  following  fac- 
tors in  the  rationale  of  the  production  of  pre- 
eclamptic toxemia  and  eclampsia,  do  I  base  my 
procedures : 

1.  Insufficient  elimination  of  toxins  gen- 
erated in  the  fetus  or  at  the  placental  site, 
coincident  with  the  increased  strain  thrown 
upon  the  maternal  organs  from  the  necessity 
of  assimilating  and  eliminating  for  both  the 
fetus  and  herself. 

2.  Infection. 

3.  Mild  asphyxia. 

Given  a  pregnant  woman.  The  growing  fe- 
tus throws  upon  the  excretory  organs  of  the 
mother,  possibly  previously  damaged  by  dis- 
eases such  as  scarlet  fever,  etc.,  double  the 
normal  load.  The  excretory  organs  may  be 
further  damaged  by  ba^jteria  or  their  toxins 
from  foci  of  infection  in  teeth,  tonsils,  colon, 
etc.    The  basic  toxin   causing   the   condition 


TOXEMIAS   OF   PKEGNANCY  43 

arises  either  from  the  fetus  or  from  the  pla- 
cental site.  Upon  the  amount  and  rapidity  of 
the  generation  of  this  toxin  and  the  ability  of 
the  excretory  organs  to  excrete  it,  depends  the 
occurrence  of  eclampsia.  The  lesions  in  the 
liver,  kidney,  heart,  etc.,  caused  by  the  toxin 
also  increase  the  deleterious  effects  upon  the 
patient.  The  demands  for  oxygen  by  the 
rapidly  growing  fetus,  especially  in  the  last 
two  or  three  months  of  pregnancy,  together 
with  a  decrease  in  the  normal  powers  of  oxy- 
genation on  the  part  of  the  mother  caused  by 
pressure  on  the  abdominal  organs  with  result- 
ing stasis,  and  caused  by  pressure  on  the  dia- 
phragm with  decreased  lung  expansion  and  in- 
terference with  the  heart,  produce  a  low  grade 
asphyxia  in  the  mother.  This  asphyxia  lowers 
the  resistance  of  the  organs  to  the  attack  of  the 
toxin  and  increases  the  extent  of  the  lesion  in 
the  liver  and  kidneys.  The  asphyxia  increases 
the  blood  pressure  by  acting  on  the  adrenal 
glands  and  causing  an  increased  amount  of 
adrenalin  in  the  blood.  The  asphyxia  likewise 
manifests  itself  in  the  increase  in  the  acidity 
of  the  hydrogen-ion  concentration  with  the 
varying  degree  of  acidosis. 

Based  upon  such  a  rationale  of  the  produc- 
tion of  eclampsia,  the  following  broad  lines  of 


44  TALKS   ON   OBSTETKICS 

prophylaxis  and  treatment  would  suggest  them- 
selves : 

1.  Protect  the  excretory  organs  by  nonirri- 
tating  food  and  keep  the  channels  of  elimina- 
tion, skin,  bowels  and  kidneys  active. 

2.  Eradicate  as  far  as  possible  or  plausible 
all  foci  of  infection. 

3.  Combat  asphyxia  by  fresh  air  and  all 
methods  for  promoting  deep  breathing  and 
keeping  up  the  general  circulation. 

4.  Combat  the  manifestation  of  acidosis  by 
alkaline  salts  and  food. 

5.  In  extremity,  remove  the  products  of  con- 
ception as  rapidly  as  is  consistent  with  freedom 
from  shock  and  the  integrity  of  the  soft  parts 
of  the  mother. 

Before  leaving  the  theory  of  toxemia  to  go 
into  the  minutiae  of  prophylaxis  and  treatment 
let  me  briefly  enumerate  certain  observations 
from  clinical  material  and  animal  experimenta- 
tion that  should  be  of  interest  to  every  student 
in  attacking  this  interesting  problem. 

Note  the  following  points: 

The  evident  relief  following  delivery  in  most 
cases  of  toxemia,  which  would  point  either  to 
a  toxin  elaborated  by  the  fetus  or  the  placenta. 
One   of   the   most   suggestive   articles   that   I 


TOXEMIAS   OF   PREGNANCY  45 

have  read  concerning  a  toxin  elaborated 
by  the  placenta  was  written  by  James  Young, 
of  Edinburgh,  appearing  in  the  Journal  of 
Obstetrics  and  Gynecology  of  the  British 
Empire,  July,  1914,  entitled  ^*The  Etiology 
of  Eclampsia  and  Albuminuria  and  Their 
Eelation  to  Accidental  Hemorrhage."  Young 
believes  that  thromboses  in  the  ovarian  and 
uterine  vessels  cause  hemorrhages  or  areas  of 
necrosis  in  the  placenta  according  as  veins 
or  arteries  are  occluded,  and  that  the  toxins 
generated  in  the  autolysis  of  these  areas  are 
the  toxins  basically  responsible  for  the  toxemia. 
He  goes  so  far  as  to  suggest  that  a  postpartum 
eclampsia  may  warrant  an  exploration  of  the 
uterus  for  retained  portions  of  the  placenta. 
Before  condemning  his  theory,  read  his  article 
and  observe  your  cases. 

Coupling  Young's  theory  with  the  theory  of 
the  infectious  origin  of  eclampsia,  note  the  close 
connection  between  most  thromboses  and  in- 
fection and  in  your  cases  note  the  high  per- 
centage of  toxemia  of  pregnancy  and  accidental 
hemorrhage  in  which  definite  foci  of  infection 
can  be  demonstrated. 

In  relation  to  asphyxia  from  pressure,  note 
that  toxemia  occurs  most  frequently  in  primip- 
ara,  multiple  pregnancies  and  hydramnios,  in 


46  TALKS   ON    OBSTETRICS 

other  words  in  those  generally  subjected  to  the 
greater  pressure.  That  primipara  are  subjec- 
ted to  greater  pressure  than  multipara  can  be 
postulated  from  the  fact  that  in  primipara  the 
lightening  occurs  earlier  than  in  multipara  in 
whom  the  abdominal  walls  have  been  previously 
stretched.  Note  that  two  of  the  beneficial 
effects  of  delivery  may  arise  from  the  conse- 
quent relief  of  pressure  and  the  throwing  of 
the  child  on  its  own  mechanism  for  oxygen- 
ation. 

Note  the  experiments  in  chloroform  poison- 
ing in  which  lesions  are  found  in  the  liver  and 
kidneys  identical  mth  those  found  in  certain 
cases  of  eclampsia.  Two  poisons  giving  the 
same  lesions  may  be  amenable  to  the  same  ther- 
apeusis.  We  may  learn  three  things  from  these 
experiments:  the  danger  of  giving  chloroform 
to  a  toxic  woman  and  thereby  increasing  the 
lesion;  that  experiments  on  rats  point  to  the 
fact  that  an  asphyxia  obtaining  in  the  presence 
of  a  circulating  poison  such  as  chloroform, 
causes  an  increase  in  the  liver  and  kidney 
lesions ;  and  that  the  diet  that  protects  the  liver 
cells  in  chloroform  poisoning  is  one  high  in  car- 
bohydrates and  low  in  proteid  and  fat,  es- 
pecially low  in  the  latter.    May  we  not  apply 


TOXEMIAS   OF   PREGNANCY  47 

these  facts  in  fighting  the  toxin  causing  pre- 
eclamptic toxemia  and  eclampsia? 

Note  the  similarity,  early  brought  out  by 
various  writers,  between  the  kidney  lesions  of 
sepsis  and  eclampsia. 

Note  the  presence  of  acidosis  in  certain  cases 
of  eclampsia  and  then  follow  the  work  of  Martin 
Fischer  on  the  relation  of  edema  to  acidosis, 
with  the  advice  as  to  the  use  of  the  salts  best 
calculated  to  overcome  the  edema.  In  this  con- 
nection note  the  use  of  magnesium  sulphate. 

In  connection  with  edema  note  the  contention 
of  such  a  man  as  Zangermeister  that  eclampsia 
may  be  caused  by  edema  of  the  brain. 

In  relation  to  asphyxia  and  the  increase  in 
the  liver  and  kidney  lesions  note  the  early  em- 
piric use  by  Stroganoff  of  oxygen  in  the  eclamp- 
tic seizures. 

Note  the  experiments  of  Cannon  showing 
that  asphyxia  will  increase  the  output  of  ad- 
renalin, thereby  causing  a  rise  in  blood  pres- 
sure and  an  increase  in  the  coagulability  of  the 
blood,  both  of  which  are  found  in  eclampsia  in 
the  latter  months. 

I  am  turning  the  mirror  here  and  there  in 
the  various  fields  of  experimentation  and  clini- 
cal observation  in  the  hope  that  the  student 
may  get  some  suggestive  reflection  from  the 


48  TALKS    OK   OBSTETRICS 

angle  at  which  he  is  viewing  the  subject,  which 
may  give  him  some  cine  for  new  stndy  and 
observation.  No  field  in  obstetrics  offers  a 
greater  field  for  stndy  and  research  and  each 
case  shonld  be  studied  intensively  from  every 
conceivable  standpoint,  in  the  determination  to 
discover  some  more  successful  method  of  pre- 
vention or  treatment  than  now  obtains. 

To  return  to  prophylaxis  and  therapy.  With 
our  present  knowledge  how  should  we  set 
about  to  limit  the  ravages  of  this  complication? 

We  should  use  every  possible  method  for 
educating  the  public  to  the  fact  that  women 
should  place  themselves  under  care  as  early  as 
possible  in  pregnancy.  This  can  best  be  done 
by  furthering  the  propaganda  for  pre-natal 
care.  Mothers  will  do  more  for  the  care  of 
their  offspring  than  they  will  do  for  themselves. 

The  pregnant  woman  should  be  given  a  thor- 
ough physical  examination.  Special  attention 
should  be  given  to  locating  foci  of  infection. 
The  teeth  should  be  thoroughly  examined 
and  the  patient  specifically  advised  to  see  her 
dentist  and  remain  under  his  care  throughout 
pregnancy.  All  visible  signs  of  destruction 
and  infection  in  the  oral  cavity  should  be 
treated.  If  the  patient  gives  a  history  of 
rheumatic   manifestations,    such   as   muscular 


TOXEMIAS   OF   PREGNANCY  49 

pains,  neuritis,  etc.,  we  should  go  farther  and 
have  the  teeth  in  which  the  nerves  have 
been  killed,  x-rayed.  Be  suspicions  of  all 
crowned  teeth.  *^  Uneasy  lies  the  head  that 
wears  a  crown. ' '  If  symptoms  of  local  inflam- 
mation or  systemic  absorption  obtain,  and  ab- 
scesses are  found,  advise  the  removal  of  those 
teeth,  care  being  taken  to  extract  only  one  at 
a  time  to  avoid  a  severe  reaction  from  the  auto- 
vaccination.  In  the  face  of  definite  signs  and 
symptoms  of  infection  and  absorption,  I  believe 
the  retention  of  these  abscesses  to  be  more 
dangerous  than  their  removal.  If  definite  signs 
do  not  exist  and  it  is  decided  to  leave  the  teeth 
alone,  watch  that  woman  with  especial  care  for 
the  accession  of  toxemia.  To  me  the  removal 
of  all  obvious  foci  of  infection  means  prophy- 
laxis against  sepsis,  toxemia,  miscarriage  and 
accidental  hemorrhage.  Concerning  the  latter 
two,  more  later.  It  is  fairly  obvious  at  least 
that  the  clearing  up  of  the  oral  cavity  will  re- 
lieve the  kidneys  of  much  unnecessary  strain. 
If  oral  sepsis  can  cause  nephritis  in  the  non- 
pregnant, it  should  be  more  likely  to  do  so  in 
the  pregnant  woman.  In  the  face  of  any  infec- 
tion, such  as  pyelonephritis,  pyorrhea,  etc.,  ev- 
ery physician  should  watch  his  patient  with 
especial    care    for    the    accession  of  toxemia. 


50  TALKS   ON    OBSTETRICS 

Nearly  every  student  asks,  **Wliy  this  empha- 
sis on  infection?^'  First,  I  have  not  yet  seen  a 
case  of  eclampsia  in  which  a  focus  of  infection, 
and  generally  a  marked  one,  conld  not  be  dem- 
onstrated. I  have  seen  case  after  case  develop 
a  toxemia  in  which,  working  on  this  theory,  I 
had  looked  for  toxemia  with  especial  care.  I 
have  seen  cases  that  a  week  before  delivery 
showed  no  signs  of  toxemia  in  nrine  and  blood 
pressure,  but  started  to  show  an  albuminuria 
and  continual  rise  of  blood  pressure  three  days 
before  delivery.  They  were  placed  immediately 
on  treatment  and  even  then  just  got  over  the 
rope,  as  it  were,  their  urine  boiling  nearly 
solid  at  delivery,  the  blood  pressure  high  and 
with  everything  ready  to  assist  delivery  if 
convulsions  obtained.  As  I  say,  I  suspected 
these  cases  because  of  evident  foci  of  infection 
which  could  not  be  cleared  up.  Second,  notice 
the  number  of  eclampsia  cases  running  a  tem- 
perature when  first  seen  and  thus  not  ac- 
counted for  by  manipulation;  third,  note  the 
number  of  multiparse  with  toxemia  who  have 
had  previous  normal  pregnancies  and  labors, 
but  who  give  definite  histories  of  symptoms 
of  infection  occurring  since  the  last  labor 
and  especially  during  the  pregnancy  in  which 
the  toxemia  occurs.    These  are  the  reasons  why 


TOXEMIAS   OF  PEEGNANCY  51 

I  have  come  to  emphasize  the  possible  role  of 
infection. 

Give  explicit  directions  that  the  bowels 
should  move  once  a  day,  and  instruct  the  pa- 
tient to  notify  yon  if  persistent  constipation 
exists.  Not  only  do  free  bowel  movements  re- 
move excretory  products  and  bacteria  and  their 
toxins  from  the  system,  that  wonld  otherwise 
have  to  be  removed  by  the  kidneys,  bnt  they 
tend  to  prevent  injury  to  the  intestine  due  to 
large  hard  fecal  masses  trying  to  pass  obstruc- 
tions caused  by  unusual  pressure  condition  with 
resultant  infection  of  the  blood  stream.  That 
colon  bacilli  gain  entrance  to  the  blood  stream 
is  evidenced  by  the  frequency  of  hematogenous 
infection  of  the  kidney.  Obstruction  from  pres- 
sure must  also  disturb  the  normal  balance  of 
bacterial  life  in  the  bowel  with  the  generation 
of  particularly  toxic  products.  The  bowels 
should  be  kept  active  by  fruit,  coarse  cereals 
and  vegetables,  and  if  necessary  by  aperients. 

The  patient  should  be  instructed  to  drink 
from  six  to  eight  glasses  of  water  daily  to  aid 
in  flushing  out  the  kidneys,  bowels  and  skin. 
The  skin  should  be  kept  active  by  bathing. 

The  patient  should  be  instructed  not  to  eat 
more  than  once  a  day. 

With  the  object  of  preventing  a  low  grade 


52  TALKS   ON   OBSTETRICS 

asphyxia  she  should  be  in  the  fresh  air  and 
sunlight  as  much  as  possible,  and  exercises 
and  massage  should  be  used  to  promote 
the  general  circulation.  The  hemoglobin  con- 
tent of  the  blood  should  be  estimated  and  in- 
creased if  need  be  by  the  administration  of  iron 
compounds  in  addition  to  the  iron  obtained  in 
the  diet. 

The  patient  should  have  definite  instructions 
to  have  the  urine  examined  at  stated  intervals. 
Once  a  month  for  the  first  six  months  and  once 
a  week  after  that  until  delivery.  More  fre- 
quently, of  course,  if  the  accession  of  untoward 
symptoms  demands. 

The  blood  pressure  should  be  taken  with  in- 
creasing frequency  toward  the  seventh  month 
and  after.  A  rising  blood  pressure  or  any 
blood  pressure  above  150  mm.  should  be  looked 
upon  with  suspicion  and  the  patient  watched 
very  closely.  The  blood  pressure  often  gives 
a  warning  of  the  onset  of  toxemia  before  evi- 
dences are  present  in  the  urine. 

Women  should  be  instructed  to  notify  the 
physician  immediately  upon  the  accession  of 
any  possible  signs  of  an  approaching  toxemia; 
persistent  headache,  disturbance  of  vision, 
edema  of  feet,  hands  or  face,  scanty  urine, 
pains  in  abdomen  and  nausea  and  vomiting. 


TOXEMIAS   OF   PREGNANCY  53 

Prophylaxis  and  early  recognition  are  the 
keynotes  in  attacking  this  condition. 

The  immediate  treatment  of  a  beginning  tox- 
emia is  merely  an  accentuation  of  the  prophy- 
lactic treatment. 

View  every  case  of  albuminuria  with  suspi- 
cion, but  you  will  find  that  many  will  prove  to  be 
transitory  under  the  simple  treatment  of  rest 
in  bed,  milk  diet  for  a  few  days,  free  catharsis 
daily  by  means  of  magnesium  sulphate  and  a 
copious  intake  of  fluid. 

If  no  improvement  results: 

See  to  it  that  the  patient  is  in  a  well-venti- 
lated sunny  room,  and  prevent  circulatory  sta- 
sis by  the  assumption  of  the  dorsal,  prone,  and 
knee-chest  positions  together  with  massage  and 
calisthenics. 

See  that  the  teeth  are  kept  clean.  Have  den- 
tal treatments  continued  at  the  home  if  neces- 
sary. 

Produce  free  catharsis  by  the  administration 
of  one  ounce  of  magnesium  sulphate  every 
morning  and  give  a  glass  of  water  every  hour. 

Increase  the  alkalinity  of  the  blood  by  giving 
organic  acids  such  as  lemonade  or  orangeade. 
Diuresis  may  be  increased  by  administering 
Imperial  Drink;  cream  of  tartar,  drams  three; 
sugar  of  milk,  drams  four;  lemon  juice,  one 


54  TALKS    ON   OBSTETRICS 

ounce;  sugar,  one  ounce;  dissolved  in  three 
pints  of  boiling  water.  This  may  be  taken  in- 
stead of  the  water  alone. 

Many  patients  seem  to  weaken  considerably 
on  solely  a  milk  diet  if  used  for  any  length  of 
time.  Place  on  a  cereal,  whey,  and  sugar  diet, 
with  a  free  use  of  buttermilk  if  the  patient  can 
take  it.  In  giving  nourishment  the  object  is  to 
give  a  diet  high  in  carbohydrate,  with  enough 
proteid  to  sustain  the  nitrogen  equilibrium,  and 
very  low  in  fat.  The  use  of  cereals,  whey, 
skimmed  milk  or  buttermilk  and  sugar  fulfills 
these  conditions.  (Opie  and  Alford  in  an  arti- 
cle appearing  in  the  Journal  of  the  American 
Medical  Association,  March  21,  1914,  give  ex- 
perimental data  which  lead  them  to  believe  that 
carbohydrates  may  be  found  to  influence 
favorably  the  course  of  pathologic  conditions 
caused  by  chloroform  and  pregnancy,  whereas, 
fat  may  cause  grave  trouble.  We  know  the 
deleterious  action  of  high  proteid.) 

Wash  out  the  lower  bowel  daily  with  high 
colon  irrigation,  taken  in  the  knee-chest  posi- 
tion, and  containing  one  per  cent  sodium  bicar- 
bonate. This  removes  toxins  and  tends  to  re- 
duce acidosis. 

Keep  the  skin  active  by  sponge  baths,  avoid- 
ing any  chilling  of  the  patient. 


TOXEMIAS   OF   PREGNANCY  55 

Assure  plenty  of  sleep. 

By  the  use  of  these  methods  of  treatment, 
many  cases  will  either  clear  up  entirely  or  can 
be  carried  through  delivery  without  the  acces- 
sion of  eclampsia. 

When  should  we  consider  emptying  the 
uterus  ? 

I  believe  the  following  danger  signals  will 
prove  as  valuable  as  any: 

Examine  the  urine  once  or  twice  daily  as  the 
gravity  of  the  case  demands.  Use  the  acetic 
acid  and  heat  test  and  allow  the  test  tubes  to 
stand  in  a  rack  so  that  the  depths  of  the  pre- 
cipitates may  be  compared  from  day  to  day. 
If  the  albumen  rises  to  fifty  per  cent  by  volume 
when  the  patient  is  on  treatment,  consider  seri- 
ously hastening  the  emptying  of  the  uterus.  If 
the  urine  of  the  patient  contains  more  than 
eighty  per  cent  albumen  by  volume  when  first 
seen,  consider  the  induction  of  labor.  If,  on  the 
other  hand,  when  the  patient  is  first  seen,  she 
has  not  been  on  treatment,  and  the  albumen 
content  is  below  eighty  per  cent  by  volume  try 
the  result  of  intensive  treatment  for  twenty- 
four  hours.  It  will  then  sometimes  fall  below 
fifty  per  cent  and  you  may  be  able  to  carry  that 
patient  through  delivery  without  need  for  inter- 
ference.   Following  this  rule  has  kept  me  from 


56  TALKS   ON   OBSTETRICS 

interfering  in  many  cases  in  which  normal  de- 
livery without  the  accession  of  eclamptic  seiz- 
ures proved  the  wisdom  of  the  delay.  Don't 
forget  the  danger  of  sepsis  in  interfering. 

The  albumen  content  alone,  however,  is  not 
a  safe  criterion.  Even  if  the  albumen  content 
is  low  and  the  blood  pressure  keeps  rising  un- 
der intensive  treatment,  it  is  not  safe  to  allow 
it  to  stay  above  180  mm.  for  long  without  inter- 
fering. If  it  reaches  200  nun.  one  should  almost 
surely  interfere. 

At  the  accession  of  convulsions  the  uterus 
would  better  be  emptied  as  quickly  as  is  con- 
sistent with  preserving  the  integrity  of  the  soft 
parts  of  the  mother  and  by  a  method  which 
will  result  in  the  least  shock.  Fortunately  in 
many  cases  we  find  that  Nature  has  attempted 
to  induce  labor,  and  that  the  cervix  is  soft 
and  beginning  to  dilate.  Why  not  let  Nature 
take  her  course  in  every  case  and  not  in- 
terfere? Believing  that  the  ultimate  toxin 
causing  the  condition  is  being  produced  either 
in  the  fetus  or  in  the  placenta,  the  sooner  the 
uterus  is  emptied  the  better  for  the  mother. 
Experience  shows  that  delivery  tends  to  ter- 
minate the  condition. 

I  have  personally  come  to  use  two  other  pos- 
sible indications  for  delivery;  the  accession  of 


TOXEMIAS   OF  PREGNAITCY  57 

eye  disturbances  with  definite  lesions  visible  in 
the  eye  grounds  and  beginning  indications  in 
the  heart  that  the  toxin  is  producing  marked 
changes,  such    as   marked  irregularity,  where 
previously  the  heart  rhythm  has  been  normal. 
There  is  one  other  type  of  case  to  which  I 
would  call  your  attention.    This  is  the  primip- 
ara  who  begins  to  have  an  increasing  toxemia 
a  month  or  two  before  term.    If  she  is  allowed 
to  go  much  over  three  weeks  with  a  severe  tox- 
emia and  you  then  attempt  to  induce  labor  es- 
pecially if  she  has  a  long  hard  cervix,  this 
woman  will  almost  invariably  die  before  you 
have  effected  delivery.    It  seems  as  if  the  se- 
vere contractions  of  labor  must  force  the  toxin 
into  the  blood  stream,  and  her  organs  have  been 
so  profoundly  affected  by  the  severe  toxemia  of 
the  previous  weeks  that  a  fatal  termination  is 
rapid.    I  do  not  believe  that  these  severe  tox- 
emia cases  should  be  allowed  to  go  without  in- 
terference for  much  over  three  weeks  and  then 
if  a  long  hard  cervix  prevents  a  rapid  delivery, 
I  believe  we  should  do  a  Cesarean. 

In  most  cases  the  albumen  and  blood  pres- 
sure will  help  the  decision  as  to  interference, 
but  I  know  of  no  condition  in  which  so  many 
factors  must  influence  the  decision  and  where  it 
is  so  impossible  to  give  definite  rules.    In  the 


58  TALKS   ON   OBSTETRICS 

long  run,  I  believe  the  attention  to  the  albumen 
and  blood  pressure  rules  as  given  above  will 
result  in  the  greatest  success. 

When  we  have  decided  that  the  uterus  should 
be  emptied,  w^e  must  remember  in  our  proce- 
dure not  to  do  anything  that  will  injure,  produce 
shock  or  lower  the  recuperative  power  of  the 
patient.  If  the  cervix  is  soft  and  dilatable  with 
the  fingers,  do  a  version  and  breech  extraction 
if  the  head  is  not  engaged.  If  the  cervix  is  di- 
lated and  the  head  tightly  engaged  deliver  with 
forceps.  If  the  cervix  is  not  dilatable  with  the 
fingers,  insert  a  Yorhees  bag  and  allow 
the  cervix  to  dilate  and  soften  sufficiently 
to  permit  manual  dilatation.  Eapid  forcible 
dilatation  of  a  more  or  less  rigid  cervix  with 
delivery,  otherwise  known  as  accouchement 
force,  is  dangerous  for  the  mother  because  of 
shock,  and  lacerations  with  increased  danger 
of  infection.  If  labor  has  not  begun,  induce  it 
with  bougie  and  gauze  packing  if  necessary,  but 
if  a  Vorhees  bag  can  possibly  be  inserted  I  be- 
lieve it  is  better  to  use  it  in  preference  to  other 
methods.  Do  not  rupture  the  membranes,  as 
the  drainage  of  liquor  amnii  may  make  a  sub- 
sequent version  dangerous  or  impossible.  With 
a  long  rigid  cervix  and  a  live  child  in  the  pres- 
ence of  a  rapidly  increasing  toxemia  or  fre- 


TOXEMIAS   OF   PREGNAITCY  59 

quent  convulsions,  I  believe  a  Caesarean  is  indi- 
cated. These  patients  are  poor  risks  for 
Caesarean  section,  but  the  strain  of  a  long  labor 
with  a  rigid  cervix  is  as  hard  on  the  mother 
as  the  strain  of  Caesarean  section,  and  the 
Caesarean  empties  the  uterus  immediately  and 
the  toxins  are  not  forced  into  the  general  circu- 
lation by  the  contractions  of  the  uterus.  The 
vaginal  Caesarean  should  be  performed  only 
when  the  child  is  small.  If  you  will  watch  the 
vaginal  Caesarean  at  term  or  before  this  if  the 
child  is  large,  you  will  likely  agree  that  it  is  a 
more  serious  operation  than  the  abdominal 
Caesarean. 

Remember  the  lesions  of  chloroform  poison- 
ing and  never  use  chloroform  in  any  procedure 
in  toxemia.  Use  ether.  Do  not  use  chloroform 
to  try  to  limit  the  convulsions.  For  this  rely 
on  chloral  and  eliminative  measures.  Many 
cases  of  postpartum  convulsions  and  death  may 
be  due  to  delayed  chloroform  poisoning  per  se 
or  by  increasing  the  lesion  already  caused  by 
the  toxemia.  It  has  been  stated  that  chloral 
will  produce  the  same  lesions  as  chloroform. 
The  experiments  of  J.  Gardner  Hopkins  pub- 
lished in  the  American  Journal  of  Obstetrics, 
Vol.  Ixv,  No.  4, 1912,  would  disprove  this  state- 
ment.   Hopkins  believes  *Hhat  it  is  impossible 


60  TALKS   ON   OBSTETRICS 

to  produce  by  the  administration  of  chloral  hy- 
drate necroses  in  the  liver  similar  to  those 
found  in  delayed  chloroform  poisoning  and 
eclampsia,  and  that  chloral  hydrate  produces 
no  histologic  changes  in  the  kidneys."  Do 
not  fear  the  administration  of  chloral  hydrate. 

Give  the  patient  oxygen  in  the  convulsions 
to  aid  in  overcoming  the  asphyxia. 

If  the  woman  is  progressing  rapidly  in  labor, 
do  not  interfere  and  thereby  increase  the  chance 
of  infection,  unless  the  great  severity  of  the 
condition  demands.  Put  the  woman  in  a  quiet, 
dark,  well-ventilated  room,  and  watch  for  the 
possible  accession  of  convulsions  with  a  mouth- 
gag  ever  ready  to  prevent  injury  to  the  patient. 
If  you  are  seeing  the  patient  for  the  first  time 
and  free  catharsis  has  not  already  been  ob- 
tained, produce  free  catharsis  with  magnesium 
sulphate  if  the  patient  is  conscious  or  if  un- 
conscious by  croton  oil,  drops  three,  placed  on 
the  back  of  the  tongue.  Give  an  initial  dose  of 
chloral  hydrate,  grains  thirty,  by  mouth  or  rec- 
tum as  it  is  possible,  and  repeat  this  dose  every 
four  hours  according  to  the  amount  of  restless- 
ness shown. 

Put  the  patient  on  a  Murphy  drip  containing 
one  per  cent  sodium  bicarbonate  and  six  per 
cent  glucose.    If  she  cannot  retain  this  fluid 


TOXEMIAS   OF   PREGNANCY  61 

give  the  one  per  cent  bicarbonate  solution  by 
hypodermoclysis,  great  care  being  exercised  to 
make  sure  of  the  sterility  of  the  solution  and 
the  aseptic  technic. 

Alternating  every  eight  hours  give  a  high 
colon  irrigation  of  nine  gallons  of  tap  water, 
and  a  hot  pack.  Be  sure,  however,  not  to  give 
the  hot  pack  unless  the  woman  is  absorbing 
plenty  of  water,  otherwise  the  sweating  will 
concentrate  the  toxin  in  the  blood  and  do  more 
harm  than  good. 

If  the  severity  of  the  case  demands,  just  as 
soon  as  the  cervix  has  dilated  sufficiently  so 
that  one  can  finish  the  dilatation  with  the  fin- 
gers and  do  a  version  with  breech  extraction, 
or  can  apply  the  forceps,  the  woman  would  bet- 
ter be  delivered  immediately.  After  delivery 
keep  the  woman  on  the  same  general  treatment 
until  marked  subsidence  of  symptoms  warrants 
its  discontinuance. 

Before  delivery  do  not  bleed  the  patient  for 
high  blood  pressure,  especially  if  you  are  not 
prepared  to  give  a  normal  saline  infusion  of  an 
amount  equal  to  the  amount  of  blood  taken. 
The  average  case  will  do  better  without  the 
phlebotomy  because  it  is  impossible  to  tell  how 
much  blood  the  woman  will  lose  at  delivery  and 
the  delivery  in  addition  to  the  phlebotomy  may 


62  TALKS    ON   OBSTETRICS 

bring  the  blood  pressure  too  low,  with  conse- 
quent death.  In  watching  these  cases  it  seems 
to  me  that  cases  that  have  not  been  bled  re- 
cover more  rapidly  than  those  who  have. 

If  it  seems  imperative  to  reduce  the  blood 
pressure,  use  the  fluid  extractum  Veratri  hypo- 
dermically,  beginning  mth  five  minims  and  re- 
peating every  four  hours  for  a  pulse  over  one 
hundred  in  rate  and  three  minims  for  a  pulse 
over  eighty.  The  Veratrum  both  slows  the 
pulse  and  lowers  the  blood  pressure.  I  have 
followed  carefully  the  use  of  phlebotomy  and 
Veratrum  and  have  seen  them  used  with  appar- 
ent success,  but  I  could  seldom  bring  myself  to 
believe  that  either  was  the  deciding  factor  in 
the  recovery.  Of  the  two,  however,  I  would  fa- 
vor Veratrum,  as  I  have  never  seen  it  do  harm, 
but  I  have  seen  cases  where  I  felt  sure  that  the 
phlebotomy  before  labor  in  addition  to  the  loss 
of  blood  at  labor  reduced  the  blood  pressure  to 
too  great  an  extent  mth  evident  bad  results. 
One  t^^e  of  case  definitely  demands  a  phle- 
botomy and  that  is  where  we  have  a  dilated 
right  heart  with  beginning  edema  of  the  lungs 
in  the  face  of  high  blood  pressure. 

It  will  be  noticed  that  I  have  not  mentioned 
the  use  of  morphin.  I  have  used  it  again  and 
again  according  to  the  Stroganoff  method.    My 


TOXEMIAS   OF   PREGNANCY  63 

own  results  and  observations  on  the  cases  of 
others,  lead  me  to  favor  the  emptying  of  the 
uterus.  An  initial  dose  of  morphin,  grain  one- 
fourth,  may  aid  in  reducing  restlessness,  but 
when  it  is  used  to  the  extent  of  reducing  the 
frequency  of  the  respirations,  I  believe  we  are 
doing  possible  harm  by  increasing  the  as- 
phyxia. It  may  slow  the  rapidity  of  the  labor 
which  should  not  be  sought.  Morphin  does  not 
reduce  the  reflex  irritability  of  the  cord  early 
in  its  action  as  does  chloral.  I  do  not  believe 
it  will  inhibit  convulsions  as  will  chloral.  If 
the  patient  is  mentally  restless  or  if  apparently 
suffering  from  severe  pain,  use  the  morphin  to 
attempt  to  relieve  internal  stimulation  as  we 
relieve  external  stimulation  by  placing  the 
woman  in  a  quiet  dark  room.  Stroganoff  pre- 
sents some  wonderful  statistics  which  should 
compel  the  attention  of  every  student.  His 
method  also  has  the  advantage  that  the  danger 
of  sepsis  by  interference  is  eliminated.  How- 
ever, it  is  my  personal  belief  that  all  things 
being  equal  in  two  cases  of  eclampsia  that 
woman  will  have  the  better  chance  for  life  who 
is  delivered  the  sooner,  provided  we  use  the 
best  aseptic  technic  and  use  no  measures  that 
will  produce  shock. 


64  TALKS   ON   OBSTETRICS 

All  cases  should  be  treated  at  a  hospital,  if 
possible. 

The  child  should  be  fed  artificially  until  the 
toxic  symptoms  have  cleared  up  in  the  mother. 

All  patients  should  be  watched  for  the  pos- 
sible accession  of  postpartum  eclampsia  and 
nurses  should  be  instructed  to  report  the  earli- 
est appearance  of  headache,  scanty  urine  or 
marked  somnolence. 

After  the  delivery  of  a  toxemic  woman,  the 
blood  pressure  and  the  urine  should  be  followed 
for  months,  not  only  to  direct  appropriate 
treatment,  but  because  of  the  significance  of  the 
findings  in  their  bearing  on  the  advice  to  be 
given  in  reference  to  the  danger  of  a  future 
pregnancy.  If  the  blood  pressure  and  urine 
return  to  normal  very  slowly  over  a  period  of 
months,  it  is  well  to  advise  an  interval  of  at 
least  three  years  before  attempting  pregnancy 
again.  If  the  blood  pressure  and  urinary  find- 
ings rapidly  return  to  normal,  it  seems  quite 
safe  to  attempt  pregnancy  after  one  year.  In 
both  instances,  however,  I  believe  she  should 
not  attempt  pregnancy  until  all  foci  of  infec- 
tion have  been  eradicated.  The  teeth  and  ton- 
sils should  be  examined  again  and  all  proce- 
dures taken  to  remove  any  focus  of  infection. 
The  frequency  with  which,  after  this  procedure, 


TOXEMIAS   OF   PREGNANCY  65 

albumen  will  disappear  from  the  urine  leads 
me  to  believe  that  much  of  the  transitory  al- 
buminuria of  pregnancy  may  come  from  foci 
of  infection.  This  transitory  albuminuria  was 
probably  obtained  before  pregnancy  and  was 
brought  to  the  attention  in  pregnancy  by  the 
routine  frequency  of  examination.  Such  a 
course  of  clearing  up  foci  of  infection  will  oft- 
times  result  in  the  attainment  by  the  patient  of 
better  health  than  she  has  enjoyed  in  years  and 
a  future  pregnancy  need  not  be  dreaded. 

Pernicious  Vomiting 

Under  the  caption  of  toxemias  of  pregnancy 
must  be  included  the  pernicious  vomiting  of 
pregnancy  which  at  times  results  in  death. 
Fortunately  this  form  of  early  vomiting  is  not 
very  common.  The  minor  forms  of  early  vomit- 
ing, however,  are  frequent  and  a  source  of 
much  discomfort  to  the  patient  and  perplexity 
to  the  physician. 

All  are  familiar  with  the  classification  of 
causes  into  reflex,  neurotic,  and  toxemic.  It  is 
probably  not  wide  of  the  mark  to  believe  that 
the  early  vomiting  of  pregnancy  even  in  its 
mildest  form  results  from  a  toxemia  and  that 
the  reflex  and  neurotic  elements  merely  aggra- 
vate the  condition. 


66  TALKS   ON   OBSTETRICS 

Three  fairly  plansible  nltimate  origins  of  the 
toxin  suggest  themselves: 

A  toxin  generated  from  a  pathologic  devel- 
opment of  the  corpus  Inteum  of  pregnancy. 

A  toxin  developed  from  autolysis  of  areas  in 
the  developing  decidna  caused  by  interference 
in  the  blood  supply  in  the  rapidly  developing 
organ. 

A  toxin,  a  foreign  protein  representing  the 
male  element  of  the  developing  ovum. 

As  in  pre-eclamptic  toxemia  the  ultimate  na- 
ture of  the  toxin  is  a  matter  of  conjecture. 
Thus  our  treatment  must  be  guided  by  the  re- 
sults of  clinical  observation,  and  the  results  of 
autopsy  findings  together  with  such  experi- 
mental data  as  may  bear  upon  the  subject  in 
an  indirect  way. 

The  follomng  facts  may  give  us  guides  for 
treatment : 

At  autopsies  of  fatal  cases  of  pernicious  vom- 
iting, we  often  find  lesions  of  the  liver  similar 
to  those  found  in  delayed  chloroform  poison- 
ing and  acute  yellow  atrophy  of  the  liver. 
These  lesions  are  a  central  necrosis  of  the  liver 
lobule  with  a  fatty  degeneration  extending  with 
diminishing  intensity  to  the  periphery  of  the 
lobule.  Experimental  chloroform  poisoning 
gives  these  lesions  in  animals.    It  may  be  fair 


TOXEMIAS   OF   PREGNANCY  67 

to  assume  that  any  treatment  that  will  diminish 
the  extent  of  the  lesion  in  experimental  chloro- 
form poisoning  may  also  diminish  the  extent  of 
the  lesion  caused  by  a  toxin  producing  identical 
lesions,  whatever  that  toxin  may  be.  Experi-^ 
ments  point  to  the  fact  that  fresh  air  and  oxy- 
gen, and  a  high  carbohydrate  diet  will  tend  to^ 
limit  the  liver  lesions  of  chloroform  poisoning. 
Let  lis  use  these  data  in  pernicious  vomiting. 

In  cases  of  pernicions  vomiting  an  acidosis  is 
present.  If  it  is  the  result  of  starvation,  we 
should  seek  to  overcome  it  by  feeding.  "We  can 
also  attempt  to  overcome  it  by  the  administra- 
tion of  salts  such  as  sodium  bicarbonate  and  by 
the  administration  of  glucose. 

It  is,  of  course,  a  well  recognized  fact  that 
the  removal  of  the  products  of  conception  will 
bring  about  a  cure  provided  it  is  done  before 
the  toxin  has  produced  irreparable  damage. 
Few  cases  necessitate  abortion  and  it  should  be 
a  last  resort.  The  problem  as  to  when  an  abor- 
tion is  indicated  is  a  difficult  one.  Many  women 
have  died  because  a  therapeutic  abortion  was 
not  performed  soon  enough  and  on  the  other 
hand  the  frequent  recovery  without  abortion 
after  the  most  serious  symptoms  and  the  pos- 
sibility of  malingering  on  the  part  of  the  pa- 
tient make  one  hesitate  to  induce  abortion.    It 


68  TALKS   ON   OBSTETRICS 

is  to  be  hoped  that  we  may  some  day  have  a 
test  by  which  we  may  recognize  in  time  the 
cases  imperatively  calling  for  interference. 

To  turn  to  actual  treatment.  Eecognizing 
the  possible  aggravating  factor  of  reflex  irrita- 
tion, we  should  make  sure  that  pelvic  relations 
and  conditions  are  normal.  Most  likely  all  have 
seen  cases  improve  markedly  after  the  reposi- 
tion of  a  retroflexed  uterus.  "We  should  see  to 
it  that  the  rectum  is  not  loaded  with  feces  and 
relieve  all  conditions  likely  to  cause  local  circu- 
latory disturbance.  Though  these  are  factors 
to  be  considered  I  believe  they  are  the  least 
important. 

The  aggravating  influence  of  the  mind  is  an 
undoubted  fact.  Counting  out  positive  malin- 
gerers who  desire  if  possible  to  force  an  abor- 
tion, there  are  countless  women  who  because  of 
fear  of  labor,  fear  of  economic  conditions  in  the 
home,  fears  engendered  by  difficulties  in  past 
pregnancies,  etc.,  are  rendered  mentally  unsta- 
ble and  apprehensive  and  this  neurotic  condi- 
tion increases  to  sometimes  an  alarming  extent 
the  symptoms  originated  by  the  causative  toxin. 
It  has  been  my  experience  that  psychotherapy 
will  relieve  more  patients  than  any  other  rem- 
edy. Try  to  find  the  source  of  the  worry  and 
overbalance  it  with  well  chosen  counter  sugges- 


TOXEMIAS   OF   PREGNANCY  69 

tions.  I  have  often  failed  in  this  and  seen  the 
patient  recover  with  remarkable  rapidity  under 
the  guidance  of  some  Faith  cure.  The  response 
to  suggestion  is  too  frequent  and  too  marked  to 
be  a  coincidence. 

Next  to  psychotherapy,  fresh  air  seems  to  be 
the  most  efftcient  remedy.  Its  rationale  is 
likely  the  better  oxygenation  of  the  blood  with 
increased  oxydizing  and  destruction  of  the 
toxin,  affording  protection  to  liver  and  kidneys. 
Stimulate  and  equalize  the  circulation  by  light 
exercises  in  the  open  air  or  by  judicious  mas- 
sage if  necessary. 

Let  the  diet  be  high  in  carbohydrates,  bal- 
anced in  proteids  and  very  low  in  fats,  cereals, 
sugar,  buttermilk,  etc.  Ofttimes  the  taking  of 
food  before  rising  will  mitigate  the  morning 
nausea.  Light  meals  at  frequent  intervals  are 
better  than  larger  meals  at  longer  intervals. 

The  excretory  channels,  bowels,  kidneys,  and 
skin  should  be  kept  in  their  highest  state  of  ef- 
ficiency. 

We  should  see  to  it  that  the  patient's  teeth 
are  in  good  condition  and  that  she  is  not  swal- 
lowing large  quantities  of  pus  resulting  from 
pyorrhea  or  caries.  The  worst  case  of  pyor- 
rhea that  I  have  ever  seen  was  present  in  the 
mouth  of  a  woman  who  eventually  died  of  per- 


70  TALKS    OjST   obstetrics 

nicioiis  vomiting.  Her  liver  gave  the  appear- 
ance of  acute  yellow  atrophy.  Whatever  the 
basic  cause  of  the  lesion  certainly  the  swallow- 
ing of  huge  quantities  of  pus  may  have  has- 
tened the  outcome. 

In  the  drugs  given  by  mouth  such  as  cerium 
oxalate,  etc.,  that  are  said  to  allay  the  nausea 
and  vomiting  I  believe  you  will  lose  confidence. 
It  is  my  opinion  that  if  they  act  at  all  it  is 
through  suggestion.  Better  the  psychotherapy 
alone  without  a  drug  that  may  have  a  deleteri- 
ous effect  upon  the  digestive  processes.  If  psy- 
chotherapy is  not  sufficient  sedative,  turn  to 
bromids  and  chloral  given  by  rectum.  Twenty 
grains  of  sodium  bromid  dissolved  in  one-half 
cup  of  warm  water  and  given  by  rectum  twice  a 
day  every  four  or  six  hours  according  to  the 
necessity  of  the  case  will  often  prove  of  great 
value.  If  this  is  not  effective,  add  ten  grains 
of  chloral  hydrate  to  each  dose  of  the  bromid. 
Avoid  the  use  of  drugs  if  possible  and  regard 
them  as  mere  adjuvants  to  tide  the  patient  over 
until  with  fresh  air  and  high  carbohydrates  and 
under  the  influence  of  rest  the  patient  has  over- 
come the  toxin  whatever  it  may  be. 

The  severe  cases  are  confined  to  bed  and 
cannot  retain  fluid  or  solids  given  by  mouth. 
These  patients  must  be  fed  by  nutrient  enemas. 


TOXEMIAS   OF   PREGNANCY  71 

Introduce  fluids  by  means  of  tlie  Murphy  drip. 
The  solution  thus  given  should  contain  five  per 
cent  sodium  bicarbonate  and  six  per  cent  glu- 
cose. Thus  we  may  introduce  fluids,  attempt  to 
reduce  the  acidosis  and  may  seek  to  protect  the 
liver  and  kidney  cells  by  the  carbohydrate  con- 
tent which  will  also  tend  to  overcome  acidosis 
caused  by  starvation. 

High  colon  irrigations  are  important  to  re- 
lieve the  lower  bowel  of  possible  toxic  products. 

Acting  on  the  supposition  that  the  corpus 
luteum  has  some  share  in  the  causation  of 
the  toxic  process,  it  has  been  given  hypo- 
dermically  and  good  results  reported,  es- 
pecially by  Hirst.  The  fact  that  this  nausea 
and  vomiting  comes  at  the  time  when  there  is 
a  change  going  on  in  the  corpus  luteum,  sug- 
gests so  forcibly  a  possible  dependence  upon 
abnormal  internal  secretion  from  that  source 
that  all  literature  bearing  on  the  subject  should 
be  followed  closely. 

As  to  when  a  therapeutic  abortion  should  be 
advised,  it  is  still  a  question  of  judgment. 
Close  observation  of  the  general  condition  of 
the  patient,  together  with  the  findings  of  the 
degree  of  acidosis  as  evidenced  in  the  ammonia 
coefficient  in  the  urine  and  the  way  it  responds 
to  psychotherapy,  fresh  air  and  forced  feeding 


72  TALKS    OIT   OBSTETRICS 

and  the  administration  of  salts  such  as  sodium 
bicarbonate  can  be  our  guides  in  rendering  this 
judgment. 

In  performing  the  abortion,  if  in  consultation 
the  same  has  been  deemed  necessary,  play  safe 
and  do  not  use  chloroform  as  an  anesthetic.  It 
may  increase  lesions  possibly  already  present. 

Before  closing  this  subject,  I  would  like  to 
offer  a  suggestion.  Acting  on  the  supposition 
that  the  male  element  in  the  developing  fetus 
may  act  as  a  foreign  protein  and  cause  the 
symptoms  in  the  mother  if  their  proteins  are 
widely  divergent,  I  would  suggest  the  possi- 
bility that  we  might  gain  some  helpful  informa- 
tion by  testing  the  mother's  and  father's  blood 
for  hemolysis  and  agglutination  in  the  very  se- 
rious cases  as  we  do  before  transfusion.  It  is 
certainly  true  that  the  husband  is  not  a  safe 
donor  in  many  instances.  In  a  severe  case  of 
pernicious  vomiting  when  the  question  of  the 
advisability  of  doing  a  therapeutic  abortion  is  a 
moot  one,  on  all  the  evidence  at  hand,  this  ag- 
glutination and  hemolysis  test  might  be  of 
great  benefit  in  aiding  the  decision.  Though  I 
can  as  yet  offer  no  definite  statement  as  to  the 
validity  of  the  theory  or  give  enough  evidence 
pro  or  con  in  relation  to  the  actual  help  given, 
by  such  a  test  to  make  it  in  any  way  decisive, 


TOXEMIAS    OF    PREGNANCY  73 

I  will  say  that  it  is  my  belief,  at  present  at 
least,  that  in  a  borderline  case  the  presence  of 
agglutination  and  hemolysis  would  increase  my 
leaning  to  the  side  of  the  advisability  of  thera- 
peutic abortion. 

In  regard  to  this  theory  postulating  the  pos- 
sible toxic  reaction  of  the  male  element  of  the 
fetus  upon  the  mother,  certain  observations  are 
interesting  for  consideration.  Does  not  the 
condition  recall  somewhat  the  symptoms  en- 
countered in  the  struggle  to  elaborate  anti- 
bodies or  antitoxins!  May  not  a  rapid  abate- 
ment of  symptoms  connote  that  a  probable  bal- 
ance may  have  been  reached? 

Concerning  the  probable  difference  in  a  wom- 
an's reaction  to  different  male  elements,  ob- 
serve the  difference  in  the  pregnancies  with 
first  and  second  husbands.  With  one  the  early 
vomiting  may  be  absent  or  negligible  and  with 
the  other  serious. 

It  has  been  said  that  pernicious  vomiting  is 
less  frequent  in  England  and  Germany  than  in 
America.  With  due  consideration  for  the  neu- 
rotic differences,  cannot  the  more  frequent 
marriage  of  divergent  strains  in  the  United 
States  offer  an  explanation? 

Such  speculations  are  justified  here  only  by 
the  interest  of  all  students  in  the  problem  to  be 
worked  out  in  the  future. 


CHAPTER  in 

HEMOEEHAGE  IN  OBSTETEICS 

In  covering  sepsis  and  the  toxemias  of  preg- 
nancy we  have  covered  seventy-five  per  cent  of 
the  causes  of  death  in  the  present  day  practice 
of  obstetrics.  We  wiU  now  take  up  a  group  of 
conditions  marked  by  hemorrhage,  which  con- 
ditions are  responsible  for  approximately  fif- 
teen per  cent  of  the  deaths  in  obstetrics.  They 
are: 

1.  Postpartum  hemorrhage. 

2.  Placenta  pre\T.a. 

3.  Accidental  hemorrhage.  (Premature  sep- 
aration of  the  placenta.) 

4.  Ectopic  pregnancy. 

5.  Euptured  uterus. 

6.  Abortion  and  miscarriage. 

Postpartum  Hemorrhage 

Serious  postpartum  hemorrhages,  though  al- 
ways to  be  guarded  against  by  preparation  and 
technic,  are  fortunately  comparatively  rare. 
If  we  designate  every  case  as  a  postpartum 

74 


HEMORRHAGE   11^   OBSTETRICS  75 

hemorrhage  that  shows  sixteen  ounces  by 
weight  of  hemorrhage,  it  is  a  comparatively 
frequent  condition.  This  is  done  in  some  rec- 
ords. If  one  will  measure  the  blood  and  follow 
these  cases  closely,  he  will  see  that  it  is  mis- 
leading to  so  designate  a  postpartum  hemor- 
rhage as  some  women  will  show  general  signs 
of  too  much  hemorrhage  when  they  have  lost 
less  than  sixteen  ounces  and  a  great  many 
women  will  show  no  general  signs  after  losing 
more  than  sixteen  oimces.  When  I  speak  of 
serious  postpartum  hemorrhages  as  being  com- 
paratively rare,  I  consider  them  from  the  stand- 
point of  general  symptoms  of  loss  of  blood  re- 
quiring treatment,  irrespective  of  the  exact 
amount  of  blood  lost.  In  eight  years  I  have 
seen  only  ten  cases.  Three  were  due  to  failure 
of  attendants  to  watch  the  uterus  for  one  hour 
after  the  delivery  of  the  placenta,  three  were 
due  to  retained  portions  of  the  placenta  and 
occurred  within  an  hour  of  the  delivery  of  the 
child  and  necessitated  manual  removal,  two 
were  due  to  the  division  of  the  cervical  artery, 
and  the  remaining  two  to  atony  of  the  uterus 
following  a  severe  and  long  drawn  out  labor. 

It  is  very  important  to  examine  the  placenta 
after  its  delivery  to  make  sure  that  no  cotyle- 
dons are  left  in  the  uterus.    If  portions  have 


r? 


6  TALKS   ON   OBSTETRICS 


remained  in  the  nterus,  that  patient  should  be 
watched  closely  and  all  preparations  made  for 
possible  interference,  made  necessary  by  hem- 
orrhage. Most  of  these  remnants  will  come 
away  without  the  necessity  for  interference. 
Many  men  make  this  an  absolnte  indication  for 
immediate  interference,  but  unless  a  man  can 
be  morally  certain  that  his  surroundings  assure 
a  perfect  aseptic  technic,  I  do  not  believe  that 
he  is  justified  in  doing  so.  From  the  standpoint 
of  sepsis  the  manual  removal  of  the  placenta 
is  one  of  the  most  dangerous  procedures,  more 
dangerous  than  a  version  because  the  maneuver 
is  not  carried  on  within  the  amniotic  sack  which 
oifers  some  protection,  but  the  hand  comes  into 
immediate  contact  with  the  uterine  sinuses. 

After  the  birth  of  the  child,  the  nurse  should 
place  her  hand  over  the  uterus  and  give  warn- 
ing if  the  uterus  balloons  up  more  than  is  nor- 
mal. She  should  not  massage  the  uterus.  I 
have  several  times  seen  this  maneuver  result  in 
a  retained  placenta,  the  cervix  contracting  and 
prohibiting  the  exit  and  the  massage  not  allow- 
ing the  normal  collection  of  blood  behind  the 
placenta  which  aids  in  its  ultimate  expulsion. 

After  the  birth  of  the  placenta,  the  nurse 
should  hold  the  uterus  and  if  the  placenta  has 
come  away  intact,  ergot  should  be  given.    The 


HEMORRHAGE   IN   OBSTETRICS  77 

nurse  should  hold  the  uterus  for  one  hour  and 
should  massage  it  if  it  becomes  flabby  and  soft. 
If  it  tends  to  remain  flabby  the  ergot  should  be 
repeated  as  often  as  necessary.  If  under  mas- 
sage and  ergot  it  will  not  contract  down  and 
hemorrhage  ensues,  use  a  sterile  intrauterine 
douche  with  the  water  at  a  temperature  of  from 
115°  to  120°  Fahrenheit.  In  every  delivery  the 
essentials  for  giving  this  sterile  douche  should 
be  prepared  for  emergency.  If  the  uterus  still 
balloons  up  tremendously,  insert  one  hand  in 
the  uterus  and  massage  the  uterus  bimanually 
v/ithdrawing  the  internal  hand  as  the  uterus 
contracts  down.  As  a  last  resource  pack  the 
uterus  tightly  with  sterile  gauze,  afterward 
continuing  the  ergot  and  massage  if  necessary. 
Be  sure  that  the  hemorrhage  is  not  coming  from 
a  perineal  or  cervical  laceration.  If  it  is,  of 
course,  immediate  ligature  is  indicated.  I  be- 
lieve that  hemorrhage  is  the  only  indication 
warranting  the  immediate  repair  of  the  cervix. 

If  general  sign^  and  symptoms  of  hemor- 
rhage obtain,  the  stoppage  of  the  hemorrhage 
must  be  followed  by  the  administration  of  flu- 
ids by  mouth.  Murphy  drip,  hypodermoclysis, 
or  transfusion  as  the  urgency  for  quick  replen- 
ishment of  fluids  demands. 

In  every  case,  normal  or  abnormal,  the  nurse 


78  TALKS    ON    OBSTETRICS 

should  watch  the  pulse  at  frequent  intervals 
and  note  any  general  signs  and  symptoms  of 
hemorrhage,  such  as  pallor,  air  hunger,  feeling 
of  f  aintness,  etc.  The  pulse  is  a  good  index  and 
every  rapid  thready  pulse  should  indicate  the 
administration  of  fluids. 

Before  leaving  every  case  the  physician 
should  satisfy  himself  that  the  woman  is  flow- 
ing normally,  that  the  uterus  is  normally  con- 
tracted and  hard,  and  that  the  pulse  is  not  ris- 
ing in  frequency.  He  should  make  it  a  rule  to 
remain  with  every  woman  for  at  least  one  hour 
after  the  birth  of  the  placenta. 

Placenta  Previa 

A  painless,  apparently  causeless  hemorrhage 
occurring  in  the  last  trimester  of  pregnancy 
should  bring  to  mind  immediately  placenta 
previa.  It  is  important  to  be  instantly  alive 
to  the  gravity  of  the  situation  and  to  remem- 
ber that  under  the  best  treatment  about  one 
in  every  six  women  with  this  complication 
dies  and  that  the  fetal  mortality  runs  as  high 
as  seventy-five  per  cent.  Go  to  that  case  with 
supplies  ready  to  pack  the  vagina  if  hemor- 
rhage demands.  A  differential  diagnosis  must 
be  made  between  this  condition  and  acciden- 
tal   hemorrhage    and    a    threatened    miscar- 


HEMORRHAGE   IN    OBSTETRICS  79 

riage.  The  absence  of  pain  points  to  pla- 
centa previa  and  the  finding  of  a  boggy  mass, 
the  placenta,  in  the  lower  nterine  segment 
impinging  on  the  cervix,  clinches  the  diag- 
nosis. Needless  to  say  it  is  ofttimes  a  difficult 
diagnosis  to  make.  It  is  often  impossible  to 
make  a  definite  diagnosis  nntil  the  patient  has 
been  under  observation  for  some  time.  In 
making  the  diagnosis  do  so  if  possible  by  means 
of  the  rectal  examination.  Eemember  that  sep- 
sis attendant  upon  lapses  in  aseptic  technic  in 
the  vaginal  examinations  and  subsequent  treat- 
ment is  responsible  for  many  deaths  in  this 
complication.  It  is  obvious  that  the  hospital 
offers  the  safest  environment  for  the  observa- 
tion and  treatment  of  these  cases. 

The  first  hemorrhage  rarely  exsanguinates  a 
woman,  but  the  second  may  and  all  prepara- 
tions should  be  made  to  meet  this  contingency. 

As  to  treatment  let  us  take  up  in  order  the 
lateral,  marginal,  partial  and  complete  vari- 
eties of  placenta  previa. 

Let  us  first  consider  those  cases  of  lateral 
placenta  previa  that  manifest  themselves  for 
the  first  time  in  labor.  The  descent  of  the  head 
often  stops  the  hemorrhage  in  these  cases  mak- 
ing interference  unnecessary.  If  interference 
is  necessary,  ofttimes  the  artificial  rupture  of 


80  TALKS   ON   OBSTETRICS 

the  membranes  will  stop  the  hemorrhage  by  al- 
lowing the  presenting  part  to  descend  and  act 
as  a  tampon.  If  this  does  not  suffice  and  the 
cervix  is  dilated  sufficiently  or  is  dilatable  with 
the  fingers,  forceps  or  version  is  indicated  ac- 
cording to  the  engagement  of  the  head.  If  a 
breech  presents  under  these  conditions,  draw 
down  a  foot. 

In  the  lateral,  marginal  and  partial  varieties, 
when  interference  is  necessary  and  the  cervix 
is  not  dilated,  the  following  courses  of  treat- 
ment may  be  used  according  to  conditions  and 
equipment;  packing  the  cervix  and  the  vagina 
with  gauze  and  repeating  the  packing  when  the 
hemorrhage  soaks  through  until  the  cervix  is 
sufficiently  dilated  to  allow  of  a  podalic  version 
and  the  bringing  down  of  a  leg  to  act  as  a  tam- 
pon ;  packing  the  cervix  and  vagina  mth  gauze 
until  the  cervix  is  sufficiently  dilated  to  admit 
of  the  placement  of  Vorhees  bags  in  increas- 
ing sizes  which  will  tampon  the  placenta 
against  the  uterus  sufficiently  to  stop  the  hem- 
orrhage and  wiU  dilate  the  cervix  until  it  is 
possible  to  do  a  podalic  version  and  draw 
down  the  leg  to  act  as  a  tampon ;  the  use  of  the 
Vorhees  bags  until  the  cervix  is  completely 
dilated  and  either  a  forceps  operation  may  be 


HEMORRHAGE   IN    OBSTETRICS  81 

consummated  or  a  breech  extraction  after  a 
version. 

In  placing  these  bags  do  not  rupture  the 
membranes  as  the  lack  of  fluid  may  interfere 
with  the  subsequent  safety  of  the  version.  If 
it  is  possible  to  insert  a  bag  and  proper  assist- 
ance is  at  hand,  do  not  use  the  gauze.  Under 
present  conditions  I  suppose  that  the  gauze 
packing  followed  by  the  manual  dilatation  of 
the  cervix  and  version  with  breech  tamponade 
or  breech  extraction  is  the  most  universal  treat- 
ment. The  bag  treatment  seems  to  give  a  lower 
mortality  for  the  mother  and  a  much  better 
prognosis  for  the  child.  If  possible  use  it 
every  time. 

In  respect  to  central  placenta  previa  with  a 
live  child  and  in  selected  cases  where  loss  of 
blood  has  not  been  extreme,  evident  sepsis  is 
not  already  present,  and  we  can  be  fairly  cer- 
tain of  the  previous  aseptic  technic  used  in  pre- 
vious vaginal  examinations,  if  any  have  been 
used,  I  believe  that  an  abdominal  Csesarean  is 
the  treatment  of  choice.  In  a  deformed  pelvis 
the  absolute  indication  holds  of  course.  The 
success  of  this  operation  will  depend  entirely 
upon  the  selective  acumen  of  the  obstetrician. 
If  the  cases  are  not  well  selected,  I  am  sure  that 
the  mortality  rate  will  be  much  higher  than 


82  TALKS    ON    OBSTETRICS 

under  the  bag  or  the  ganze  packing  treatment. 
If  bags  are  used  in  central  placenta  previa, 
do  not  go  through  the  placenta  to  place  the 
bag,  but  place  it  between  the  placenta  and 
the  cervix  and  when  the  dilatation  is  complete 
go  through  the  placenta  rapidly,  do  a  version 
and  breech  extraction  followed  by  an  immedi- 
ate manual  extraction  of  the  placenta.  Have 
everything  ready  for  an  infusion. 

Accidental  Hemorrhage  or  Premature 
Separation  of  the  Placenta 

If  called  by  any  woman  during  the  last  five 
months  of  pregnancy  because  she  has  sudden 
severe  uterine  pain  and  she  gives  evidence  of 
external  or  concealed  hemorrhage,  premature 
separation  of  the  placenta  should  immediately 
flash  across  the  mind.  The  presence  of  pain 
militates  against  the  diagnosis  of  placenta 
previa  and  the  appearance  of  the  condition  be- 
fore the  last  trimester  speaks  against  it.  The 
suddenness  and  the  severity  of  the  pain  and 
the  absence  of  premonitory  signs,  together  with 
the  lack  of  the  rhythmic  character  of  labor 
pains  speak  against  the  ordinary  miscarriage. 
Eapid  pulse,  history  of  sudden  severe  uterine 
pain,  signs  of  shock  and  hemorrhage  open  or 
concealed,  an  appreciable  rapid  enlargement  of 


HEMORRHAGE   IN    OBSTETRICS  83 

the  uterus  and  the  absence  of  a  boggy  mass  in 
the  lower  uterine  segment  point  directly  to 
premature  separation  of  the  placenta. 

Premature  separation  of  the  placenta  is  a 
very  serious  condition.  General  statistics  show 
that  in  this  condition  about  one  in  every  three 
women  die  and  that  about  three  out  of  every 
four  babies  die.  Of  course,  these  figures  vary 
greatly  according  to  the  extent  of  the  separa- 
tion of  the  placenta,  but  it  is  well  to  keep  them 
in  mind  to  impress  the  gravity  of  the  situation 
and  the  need  for  the  best  surroundings  for  the 
conduct  of  the  treatment.  All  cases  should  be 
taken  to  a  hospital  immediately,  if  the  prox- 
imity of  the  hospital  and  the  condition  of  the 
patient  render  it  possible. 

Treatment. — 

Gauze  packing  from  below  to  stop  the  hemor- 
rhage. 

Abdominal  binder  to  limit  if  possible  the  bal- 
looning out  of  the  uterus  above  and  thus  limit 
the  hemorrhage  by  pressure. 

Means  to  hurry  the  emptying  of  the  uterus 
and  allow  us  to  get  at  the  seat  of  the  hemor- 
rhage. 

To  hasten  the  emptying  of  the  uterus,  pack 
the  vagina  with  gauze  until  the  cervix  softens 


84  TALKS   ON   OBSTETRICS 

and  dilates  sufficiently  to  permit  of  the  intro- 
duction of  a  bag.  When  the  cervix  is  dilated 
sufficiently,  version  and  breech  extraction  or 
forceps,  as  conditions  dictate.  After  delivery, 
manual  extraction  of  the  placenta  if  the  hemor- 
rhage does  not  cease.  Other  means  for  stop- 
ping postpartum  hemorrhage  are  a  douche  at 
115°  to  120°  Fahrenheit,  and  gauze  packing. 
Essentials  should  be  at  hand  for  quick  replen- 
ishment of  body  fluids  after  delivery. 

The  hemorrhage  may  be  so  severe  as  to  allow 
of  no  slow  methods  of  delivery  and  accouche- 
ment force  or  Csesarean,  vaginal  or  abdominal, 
may  offer  the  only  hope  for  the  mother. 

Can  we  prevent  this  complication? 

Considering  the  accepted  causes ;  it  is  appar- 
ent that  we  cannot  prevent  all  falls  and  blows, 
nor  can  we  prevent  short  cord,  twins,  poly- 
hydramnios, all  toxemias  of  pregnancy,  syph- 
ilis, rheumatism,  endocarditis,  etc.  However, 
I  want  to  call  your  attention  again  to  the 
previously  quoted  article,  written  by  James 
Young,  who  believes  that  premature  sepa- 
ration of  the  placenta  is  due  in  many  in- 
stances to  a  thrombosis  of  the  uterine  and  ova- 
rian vessels  causing  a  hemorrhage  and  a  separa- 
tion of  the  placenta,  from  the  damming  back  of 
blood.    We  may  be  able  to  go  a  step  further 


HEMORRHAGE   IN   OBSTETRICS  85 

and  postulate  infection  or  bacterial  toxins  as  a 
possible  cause  of  the  thrombosis.  The  last  se- 
vere case  of  accidental  hemorrhage  that  came 
under  my  observation,  gave  no  history  of 
trauma,  nor  was  a  short  cord  or  any  other  ab- 
normal condition  present  except  the  presence 
of  fifteen  carious  teeth  and  a  marked  pyorrhea 
with  a  mouth  bathed  in  pus.  Note  the  list  of 
possible  causes  in  any  textbook;  endocarditis, 
rheumatism,  etc.  Eradication  of  foci  of  infec- 
tion will  prevent  or  aid  in  the  cure  of  many 
rheumatic  manifestations  and  may  it  not  pre- 
vent one  of  the  complications,  accidental  hemor- 
rhage? It  may  seem  ridiculous  to  many,  to 
harp  and  harp  on  the  subject  of  infection,  but  I 
do  not  believe  that  facts  warrant  such  an  atti- 
tude of  scoffing.  The  more  one  studies  the  dis- 
ease-processes in  plants,  lower  animals  and 
man,  the  more  one  is  led  to  recognize  the  tre- 
mendous role  played  by  bacteria.  If  we  err  at 
all,  we  do  so  on  the  side  of  forgetting  too  often 
the  great  biologic  struggle  for  existence,  with 
its  resultant  train  of  pathologic  conditions.  I 
believe  that  the  clearing  up  of  all  foci  of  in- 
fection in  pregnant  women  as  far  as  it  is  pos- 
sible or  expedient  may  aid  in  reducing  the  in- 
cidence of  accidental  hemorrhage. 


86  TALKS   ON   OBSTETRICS 

Ectopic  Pregnancy 

I  was  first  really  introduced  to  ectopic  preg- 
nancy after  having  brought  in,  as  an  ambulance 
surgeon,  a  young  unmarried  woman  with  a 
diagnosis  of  acute  appendicitis.  Pelvic  ex- 
amination at  the  hospital  showed  the  incorrect- 
ness of  my  snap  diagnosis.  Since  then  I  have 
seen  two  women  operated  on  for  appendicitis 
which  proved  to  be  ectopic  pregnancy,  two 
women  curetted  for  incomplete  abortion  with- 
out relief  because  the  real  condition  was  ectopic 
pregnancy,  and  many  women  operated  on  for 
salpingo-oophoritis  and  pelvic  abscess  that 
proved  to  be  an  ectopic. 

The  possibility  of  an  ectopic  pregnancy,  rup- 
tured or  unruptured,  should  ever  be  in  one's 
mind  when  called  to  see  a  woman  in  the  child- 
bearing  period  suffering  from  abdominal  pain 
and  uterine  hemorrhage.  I  have  fallen  down 
so  many  times  in  the  diagnosis  and  seen  others 
do  the  same,  that  the  only  advice  I  can  give  is 
to  always  keep  the  possibility  of  an  ectopic  in 
mind,  have  consultation  as  soon  as  it  is  sus- 
pected, and  rely  on  your  surgical  judgment  in 
recognizing  conditions  warranting  an  explora- 
tion if  there  is  a  question  of  diagnosis. 

I  have  seen  ectopic  diagnosed  as  dysmen- 


HEMORRHAGE   IN   OBSTETRICS  87 

orrhea,     menorrhagia,     abortion     pyosalpinx, 
ovarian   cyst,   uterine   fibroid,  pelvic  abscess, 
and  mistaken  for  acute  upper  abdominal  con- 
ditions.    Having  seen  such  situations  brings 
forcibly  to  mind  the  advantage  of  early  exami- 
nations where  a  woman  believes  she  may  be 
pregnant  so  that  a  possible  ectopic  pregnancy 
or    other  abnormal  condition  may  be  sought 
for  or  a  normal  pregnancy  diagnosed.    In  the 
presence  of  pelvic  pain  and  uterine  hemorrhage 
it  simplifies  matters  greatly  if  you  have  already 
diagnosed  a  nomal  pregnancy.    I  mention  this 
advisedly  because  I  have  often  been  called  to 
a  case  which  appears  to  be  a  case  of  threatened 
abortion  and  yet  in  which  the  diagnosis  of  a 
possible  ectopic  must  be  made  because  I  had 
not  seen  the  woman  before.    One  stands  a  bet- 
ter chance  of  quieting  do-WTi  a  threatened  abor- 
tion if  no  manual  examination  is  made.    If  for 
the  purpose  of  a  differential  diagnosis  pelvic 
examination  must  be  made,  use  the  rectal  if 
possible  to  preclude  the  possibility  of  intro- 
ducing  infection.      (I    cannot    emphasize   too 
much  the  value  of  being  expert  in  making  the 
rectal  examination.    Not  alone  in  obstetrics  and 
gynecology  is  it  of  great  value,  as  one  can  vouch 
who   has    had  experience  in  general  hospital 
training  and  can  recall  frequent  cases  of  ap- 


88  TALKS   ON   OBSTETRICS 

pendiceal  abscess  diagnosed  by  rectum  and  can 
recall  many  obscure  cases  that  have  escaped 
diagnosis  for  days  because  men  have  failed  to 
make  rectal  examinations  and  thereby  failed 
to  find  a  prostatic  abscess  that  has  given  the 
patient  no  local  pain  that  would  call  attention 
to  the  pelvis.  Its  use  in  obstetrics  instead  of 
the  routine  vaginal  examination,  I  am  certain, 
will  prevent  many  cases  of  sepsis  and  in  gyne- 
cology it  will  often  give  information  that  the 
vaginal  examination  will  not  give.) 

In  making  the  diagnosis  of  ectopic  pregnancy, 
the  symptoms  and  signs  to  be  kept  in  mind 
are:  some  irregularity  of  menstruation,  spot- 
ting, pains  in  the  pelvis,  some  enlargement  and 
softening  of  the  uterus  with  or  without  other 
presumptive  symptoms  and  signs  of  pregnancy, 
pain  on  moving  the  cervix,  a  feeling  as  if  a 
stick  were  sticking  into  the  rectum  on  defeca- 
tion, and  the  finding  of  a  tender  mass  to  any 
side  of  the  uterus.  Eemember  that  the  absence 
of  any  one  or  two  of  these  signs  cannot  exclude 
ectopic  pregnancy. 

When  the  ectopic  oozes  or  ruptures,  we 
may  have  in  addition  to  the  above,  signs  of 
internal  hemorrhage,  shock,  and  a  boggy  mass 
distending  the  pouch  of  Douglas.     The  rup- 


HEMORRHAGE   IN   OBSTETRICS  89 

tnred  ectopic  may  simulate  almost  any  acnte 
abdominal  condition. 

The  most  frequent  differentials  that  one  is 
called  to  make  are  abortion,  complete  or  incom- 
plete, pus  tubes,  and  ovarian  cyst. 

In  acute  salpingitis  the  diagnosis  is  aided  by 
finding  no  enlargement  of  the  uterus,  no  pre- 
sumptive signs  of  pregnancy,  masses  on  both 
sides  of  the  uterus,  history  of  infection  and 
positive  smears  from  urethral  and  cervical  dis- 
charges. Temperature  and  leucocytosis  may 
aid.  It  is  often  a  very  difficult  differential. 
Under  the  most  thorough  examinations,  his- 
tories and  laboratory  findings,  after  consul- 
tation you  may  operate  for  ectopic  and  find  a 
salpingo-oophoritis  and  vice  versa.  The  key- 
note to  success  is  knowing  when  an  exploratory 
should  be  done. 

The  ovarian  cyst  in  the  presence  of  presump- 
tive signs  of  pregnancy,  pelvic  pain,  and  ir- 
regular bleeding  makes  a  differential  a  puzzling 
question.  When  any  question  exists,  the  pa- 
tient should  be  under  observation  in  a  hospital. 

In  determining  the  presence  of  a  threatened 
abortion  in  a  uterine  pregnancy  we  may  have 
the  knowledge  by  a  previous  examination  of  a 
normal  pregnancy,  we  may  have  the  rhythmic 
pains  characteristic  of  labor,  or  we  may  find 


90  TALKS    OX    OBSTETPwICS 

no  change  in  the  pelvic  organs  outside  of  the 
enlarged  and  softened  11161118. 

In  cases  where  iDregnancy  is  doubted  and  de- 
lay under  observation  is  indicated,  the  Abder- 
halden  test  may  prove  of  valne,  but  at  least 
when  subject  to  the  present  possible  errors  of 
teclmic.  it  cannot  be  depended  npon  entirely. 

After  all  is  said  and  done,  in  reference  to 
this  condition  I  have  come  to  the  following 
conclusion : 

The  more  cases  that  yon  follow  in  which  it 
has  been  necessary  to  make  a  differential  di- 
agnosis betAveen  a  possible  ectopic,  especially 
before  rupture,  and  other  conditions  that  must 
be  excluded,  the  less  sure  you  w]]l  be  of  the 
diagnosis  of  the  exact  condition,  but  the  more 
sure  you  vill  be  of  the  absolute  importance  of 
a  diagnostic  care  and  acumen  and  a  surgical 
judgment  that  can  distinguish  between  the  case 
that  can  safely  be  watched  closely  without  im- 
mediate interference  and  the  case  demanding 
immediate  exploratory  laparotomy. 

Rupture  of  the  Uterus 

This  subject  is  generally  so  thoroughly 
drilled  into  students  and  the  symptoms  and 
signs  brought  out  in  such  a  spectacular  and 
tragic  manner  that  I  find  that  men  are  likely 


HEMORRHAGE    IX    OBSTETRICS  91 

to  be  unduly  nervous  from  fear  of  it  in  many 
cases  and  ofttimes  want  to  interfere  imnecessa- 
rily  thereby  courting  sepsis. 

Remember  that  most  cases  of  rnptnred 
uterus  have  resulted  from  very  poor  manage- 
ment. Eemember  that  only  about  seven  per 
cent  occur  in  primiparae,  the  remainder  occur- 
ring in  multipara  where  the  uterine  wall  is 
more  apt  to  be  flabby  and  thinned  out.  Re- 
member that  any  Ioioaaii  abnormality  of  the 
uterine  wall  such  as  a  scar  of  a  previous 
Cesarean,  especially  if  the  Ce?sarean  section 
was  followed  by  suppuration,  should  make  one 
especially  cautious. 

As  gTiards  against  a  possible  rupture  of  the 
uterus  the  following  rules  are  valuable : 

1.  Do  not  allow  the  second  stage  of  labor  to 
last  much  over  two  hours.  If  continuous  ad- 
vancement of  the  head  and  the  good  condition 
of  mother  and  child  lead  one  to  extend  some- 
what this  two  hour  limit,  watch  for  the  contrac- 
tion ring  and  do  not  let  it  rise  above  the  mn- 
bilicus  without  interfering.  If  the  uterine  wall 
is  known  to  be  pathologic,  interfere  before  the 
two  hour  limit  if  it  seems  advisable  and  most 
certainly  at  the  first  appearance  of  a  contrac- 
tion ring.  (Do  not  mistake  a  full  bladder  for 
a  contraction  ring  as  I  have  often  seen  done.) 


92  TALKS   ON   OBSTETRICS 

2.  Never  give  pituitrin  in  the  presence  of  a 
contraction  ring. 

3.  Never  give  pituitrin  unless  you  can  be  as 
certain  as  measurements  and  examinations  will 
allow  that  the  passage  offers  no  absolute  ob- 
struction to  the  passenger.  Then  give  it  in  no 
larger  than  five  minim  doses  repeated  as  often 
as  is  necessary  or  expedient. 

4.  Beware  of  attempts  at  version  if  the  amni- 
otic fluid  has  long  been  drained  away  and  the 
uterus  is  firmly  contracted  around  the  child. 

5.  Beware  of  attempts  at  version  before  the 
uterus  is  thoroughly  relaxed  under  an  anes- 
thetic. 

The  signs  of  a  possible  rupture  of  the  uterus 
are:  Tearing  pain,  shock,  hemorrhage,  reces- 
sion of  the  presenting  part  with  cessation  of 
labor  pains;  together  with  abnormal  findings 
on  abdominal  palpation. 

Laparotomy  is  indicated  immediately  upon 
the  establishment  of  the  diagnosis.  Maternal 
mortality  is  about  fifty  per  cent. 

Abortion  and  Miscarriage 

I  have  placed  this  condition  in  the  hemor- 
rhage group  to  emphasize  a  cardinal  sign  in 
diagnosis  and  not  because  hemorrhage  is  the 
frequent  cause  of  maternal  mortality.    The  dan- 


HEMORRHAGE   IN    OBSTETRICS  93 

ger  of  abortion  lies  more  in  sepsis  than  in  hem- 
orrhage. The  appreciation  of  this  fact  will 
save  the  lives  of  many  women. 

The  majority  of  hemorrhages,  preceded  or 
followed  by  abdominal  pain,  in  pregnancy  are 
the  signs  of  abortion.  From  ten  to  twenty  per 
cent  of  pregnancies  terminate  in  abortion  and 
the  possibility  of  its  accession  should  be  ever 
present  in  the  mind  of  the  physician  when  a 
patient  presents  for  care  in  pregnancy. 

A  miscarriage  is  a  great  disappointment  to 
a  mother  and  the  family  and  the  mental  de- 
pression follo\\ing  in  its  train  is  almost  as  fre- 
qnent  a  canse  of  subsequent  ill  health  in  the 
mother  as  the  physical  results  per  se.  This  is 
especially  true  if  the  miscarriage  obtains  in  the 
first  pregnancy.  In  many  such  cases  the  mental 
anxiety  jjroduced  by  the  fear  of  miscarriage 
in  a  possible  subsequent  pregnancy  may  become 
a  veritable  complication,  especially  when  a  sub- 
sequent pregnancy  ensues.  I  have  found  that 
the  most  effective  way  to  quiet  this  fear  is  to 
tell  them  that  for  some  reason  miscarriage  falls 
to  the  lot  of  most  every  woman  once  in  five 
pregnancies  and  that  she  has  suffered  her  quota 
of  misfortune.  I  then  try  to  find  the  cause  of 
the  miscarriage  as  a  means  of  future  prophy- 
laxis. 


94  TALKS   O:^   OBSTETRICS 

In  regard  to  prophylaxis.  When  a  woman 
presents  for  the  j&rst  time  in  pregnancy  we 
shonld  aim,  by  means  of  specific  written  in- 
structions and  a  thorough  physical  examination, 
to  guard  her  against  the  possibility  of  mis- 
carriage. 

The  instructions  should  caution  her  as  to  the 
danger  of  overtiring,  jolts,  jars  and  straining, 
especially  at  the  time  when  menstruation  would 
normally  be  in  progress,  at  which  time  the 
uterus  seems  especially  sensitive  to  even  slight 
stimuli.  She  should  be  cautioned  about  inter- 
course at  this  time  and  if  advisable  from  the 
previous  history,  be  advised  to  remain  in  bed 
for  a  few  days.    Douches  should  be  interdicted. 

She  should  have  definite  instructions  to  notify 
the  physician  at  the  advent  of  an  increased 
vaginal  discharge  mth  a  feeling  of  discomfort 
in  the  pelvis,  often  a  precursor  of  threatened 
miscarriage,  and  at  the  first  sign  of  spotting 
or  definite  uterine  hemorrhage,  or  pain  in  the 
abdomen. 

We  should  seek  to  protect  her  as  much  as 
possible  from  worry  and  mental  shock.  I  re- 
call one  patient  who  had  an  abortion  beginning 
at  a  moving  picture  show  depicting  ^Hwilight 
sleep."  Any  mental  shock  should  be  avoided 
if  possible. 


HEMORRHAGE   IN    OBSTETRICS  95 

It  is  not  in  the  lack  of  care  in  giving  these 
instructions  to  our  patients  that  we  are  likely 
to  err,  but  in  our  carelessness  in  making  our 
physical  examinations.  Before  bringing  out 
the  main  points  in  the  physical  examination, 
recall  to  mind  the  accepted  direct  and  indirect 
causes  of  abortion :  trauma,  mental  shocks,  de- 
velopmental anomalies  in  the  fetus  that  result 
in  its  death  and  subsequent  expulsion,  local  ab- 
normalities, such  as  retroversion  of  the  uterus, 
deep  cervical  tears,  endometrial  pathology,  etc., 
and  infections.  Criminal  abortion  we  will  omit 
from  this  discussion. 

A  large  number  of  abortions  are  the  result 
of  developmental  anomalies,  that  result  in  the 
death  of  the  fetus.  These  we  cannot  influence 
and  it  is  a  blessing  that  Nature  has  provided 
this  safety  valve,  as  it  were,  which  prevents  in 
so  many  instances  a  woman  going  to  term  and 
delivering  a  living  monstrosity. 

The  significance  of  trauma  and  mental  shocks 
we  have  mentioned. 

Of  all  other  causes,  observation  has  taught 
me  to  give  the  most  weight  to  infection.  I  am 
inclined  to  believe  that  it  is  the  most  important 
of  all  causes.  I  do  not  mean  lues  alone,  which 
we  all  know  is  a  most  important  cause  of  abor- 
tion, but  any  other  infection. 


96  TALKS   OlsT   OBSTETRICS 

If  you  will  follow  your  cases  carefully  you 
will  find  that  the  laity  believes  so  universally 
in  the  traumatic  factor  in  miscarriage  that  a 
woman  mil  often  give  a  very  vague  history  of 
trauma  that  is  likely  to  throw  one  o:ff  his  guard. 
It  reminds  me  of  the  history  of  trauma 
that  a  mother  mil  give  when  she  describes  the 
beginning  of  a  limp  in  a  child  with  a  tuber- 
culous hip.  In  many  of  these  abortions  I  feel 
certain  that  infection  of  some  sort  is  the  causa- 
tive factor  and  I  feel  that  a  physician  is  not 
doing  his  duty  to  his  patient  if  the  history  of 
a  previous  abortion  does  not  prompt  him  to 
look  for  foci  of  infection  in  addition  to  lues. 
Lues  must,  of  course,  be  excluded,  but  I  have  in 
a  great  many  instances  excluded  lues  to  the  best 
of  my  ability  by  history,  signs,  and  a  number 
of  Wassermanns  on  man  and  wife,  have  ex- 
cluded local  factors,  trauma  and  neuroses,  have 
been  morally  certain  that  artificial  means  had 
not  been  used,  and  found  carious  and  abscessed 
teeth  and  infected  tonsils,  which,  especially  in 
the  presence  of  symptoms  of  infection  such 
as  neuritis,  muscular  rheumatism,  endocarditis, 
etc.,  made  me  suspect  the  oral  and  throat  in- 
fection as  the  origin  of  the  abortion.  It  seems 
fair  to  assume  that  bacteria  from  abscessed 
teeth,  tonsils,  etc.,  that  can  form  emboli  in  mus- 


HEMORRHAGE   IK   OBSTETRICS  97 

cles  and  nerves  and  cause  rheumatism  and  neu- 
ritis, can  cause  abnormal  conditions  in  the  de- 
cidua  with  consequent  abortion.  We  know  the 
action  of  the  bacillus  abortus  in  cattle.  We 
know  that  any  infectious  disease  can  cause  an 
abortion  in  woman.  Whether  it  does  so  by 
killing  the  fetus  directly  or  indirectly  by  caus- 
ing pathology  in  the  decidua  with  the  resultant 
death  of  the  fetus  is  of  more  pathological  than 
practical  interest.  I  personally  believe  that  the 
decidua  suffers  first.  Those  of  us  who  work 
with  experimental  laboratory  animals,  such  as 
rats  for  example,  know  that  we  are  often 
handicapped  in  our  work  by  the  frequent  abor- 
tions resulting  from  infection.  I  believe  that 
infection  of  any  type,  anywhere  situated,  may 
cause  abortion  by  infarction  or  elaboration  of 
toxins.  Needless  to  say  it  will  not  always  do 
so  any  more  than  diseased  teeth  and  tonsils 
will  always  cause  rheumatic  conditions.  Even 
if  you  don't  believe  it,  keep  it  in  mind  in  care- 
fully going  over  your  cases. 

Concerning  infection,  I  would  recall  a  case 
coming  under  my  observation  lately.  She  was 
two  months  pregnant  and  suffering  from  acute 
and  rapidly  progressing  tuberculosis  of  the 
lung.  It  was  the  opinion  of  three  physicians 
that   a   therapeutic   abortion   should  be   per- 


98  TALKS   ON   OBSTETRICS 

formed.  This  she  refused  and  went  on  to  de- 
livery. The  point  of  especial  interest  in  this 
case  was  not  her  refusal  to  take  advice,  but  her 
previous  history.  Within  a  year  and  one-half 
previous  to  her  present  pregnancy  she  had 
aborted  twice.  No  history  of  trauma  in  either 
abortion.  The  tuberculosis  lesion  was  not  dis- 
covered until  the  third  pregnancy,  but  it  seemed 
fairly  certain  that  it  had  existed  in  the  previous 
pregnancies.  "What  I  want  to  emphasize  is  that 
not  only  should  a  woman  be  given  a  careful, 
thorough  physical  examination  in  applying  for 
the  first  time  in  pregnancy,  but  that  a  history 
of  previous  abortion  should  lead  every  phy- 
sician to  take  especial  care  in  the  search  for 
foci  of  infection  other  than  lues.  The  time  to 
discover  infection  is  before  or  between  preg- 
nancies. Following  an  abortion,  a  physician 
should  seek  for  and  advise  the  removal  of  all 
foci  of  infection,  such  as  diseased  tonsils,  ab- 
scessed teeth,  etc.  Search  for  tuberculous  le- 
sions. If  you  do  not  do  so,  and  she  has  an  ac- 
tive process,  she  may  not  be  so  fortunate  as  to 
abort  in  the  subsequent  pregnancy  and  the  ac- 
tive process  may  either  call  for  a  therapeutic 
abortion  or  may  cause  the  death  of  the  mother 
in  or  shortly  after  labor. 
All  pregnant  women  should  be  sent  to  their 


HEMORRHAGE   IN"   OBSTETRICS  99 

dentists  and  all  foci  of  infection  discovered.   At- 
tention to  the  teeth  in  pregnancy  will  negative 
the  old  adage,  **for  every  child  a  tooth,''  and 
the  majority  of  women  will  reach  delivery  with 
better  teeth  than  they  had  at  the  beginning  of 
pregnancy.    If  infection  is  found,  the  question 
arises  as  to  whether  it  is  safe  to  work  on  a 
woman's  teeth  in  pregnancy.    All  open  infec- 
tions can  be  treated  without  danger  by  fre- 
quent, short,  nontiring,  painless  methods.     If 
pyorrhea  is  present  the  dentist  should  exercise 
great  care  in  manipulating  the  gums  so  as  not 
to  get  a  severe  reaction  from  auto -vaccination. 
When  it  comes  to  eradicating  root  abscesses, 
the  question  is  more  difficult  of  decision.     In 
cases  giving  a  history  of  previous  abortions  or 
toxemia  of  pregnancy  and  where  definite  local 
or  general  signs  exist,  pointing  to  the  teeth 
as  a  possible  cause,  such  as  rheumatism,  neu- 
ritis, nephritis,  etc.,  I  never  hesitate  to  advise 
extraction.     The  most  painless  method  should 
be  used.    I  counsel  the  family  that  the  reten- 
tion of  these  abscesses  is  of  more  danger  to  the 
patient  than  the  possibility  of  a  miscarriage. 
It  is  a  well  known  fact  that  pregnant  women 
stand  major  operations  well  with  the  exception 
of  cervical  and  hemorrhoid  operations,  and  that 
abortion  is  likely  to  ensue  only  when  infection 


100  TALKS    OIT   OBSTETRICS 

takes  place.  In  abdominal  operations  in  preg- 
nancy, if  the  corpus  luteum  is  not  disturbed, 
abortion  is  not  likely  to  take  place  unless  infec- 
tion ensues  and  then  about  forty  per  cent  will 
abort.  Even  fibroids  may  be  removed  from 
the  pregnant  uterus  without  imtoward  result. 
Seemingly  the  infection  and  not  the  operation 
per  se  is  the  danger.  The  same  applies  to  den- 
tal operations.  In  this  connection  a  prominent 
dentist  related  to  me  a  story  of  an  experience, 
arising  in  his  early  practice.  A  woman  applied 
for  treatment  of  a  condition  that  required  an 
extensive  dental  operation.  This  was  per- 
formed under  ether  anesthesia  with  success. 
After  the  operation  she  made  the  remark  that 
^^she  hoped  that  would  fix  it."  Upon  inquiry 
as  to  what  she  meant  he  was  informed  that  she 
was  pregnant  and  had  sought  treatment  in  the 
hope  that  it  would  bring  about  a  miscarriage. 
It  did  not  do  so.  This  is  not  a  plea  for  the 
advisability  of  extensive  dental  operations, 
however.  If  extractions  are  decided  upon,  only 
one  tooth  should  be  extracted  at  a  sitting,  a 
week,  ten  days  or  two  weeks  interval  elapsing 
before  the  next  extraction  to  allow  for  reaction 
as  we  do  in  giving  autogenous  vaccine.  The 
reaction  is  often  much  the  same.  So  far,  I  have 
seen  only  one  case  in  which  a  threatened  abor- 


HEMORKHAGE   IN    OBSTETRICS  101 

tion  immediately  followed.  This  was  in  a 
highly  neurotic  woman.  Her  history  of  a  past 
abortion,  the  presence  of  definite  rheumatic 
symptoms  obtaining  from  a  time  previous  to 
her  abortion  and  the  presence  of  a  large  root 
abscess  made  it  seem  wise  to  counsel  extraction 
in  spite  of  her  highly  neurotic  temperament  As 
she  recovered  consciousness  from  the  gas  anes- 
thesia she  said  she  had  been  through  labor.  In 
about  five  minutes  she  began  to  have  pains,  and 
within  a  half  hour  she  began  to  flow.  Under 
appropriate  treatment  the  threatened  abortion 
subsided.  Marked  and  rapid  improvement  in 
her  general  health  followed  the  draining  of  this 
abscess.  Such  a  case  would  suggest  the  wise 
precaution  of  being  on  hand  to  administer  im- 
mediate treatment  for  threatened  abortion  if 
it  should  become  necessary.  An  initial  dose  of 
morphin  before  the  anesthetic  could  do  no  harm. 
Use  local  novocaine  anesthesia  where  it  is  pos- 
sible or  expedient.  Some  patients  dread  the 
thought  of  being  conscious  and  should  have  gas 
anesthesia  or  analgesia.  In  studying  gas  an- 
esthesia I  have  often  found  from  subsequent 
questioning  or  from  voluntary  statement  of  the 
patient  that  there  was  a  predominance  or 
marked  accentuation  of  a  previous  fixed  idea 
in  the  dreams  under  the  anesthetic.    In  the  case 


102  TALKS   ON   OBSTETRICS 

of  threatened  abortion  cited  above,  I  believe 
we  were  dealing  with  a  psychic  shock  produced 
by  the  intensity  of  the  dream  tinder  the  anes- 
thetic. 

It  is  obvious  that  an  incarcerated  uterus 
may  cause  an  abortion.  Do  not  think,  however, 
that  because  of  this  fact  every  retroverted 
u.terus  should  be  replaced  in  early  pregnancy. 
Most  of  these  uteri  will  rise  out  of  the  pelvis 
as  the  uterus  enlarges.  Watch  the  uterus  care- 
fully if  it  is  retroverted,  but  do  not  insert  a 
pessary  unless  observation  makes  it  seem  ab- 
solutely necessary.  I  have  seen  several  abor- 
tions foUoAving  manual  reposition  and  the  in- 
stallation of  a  pessary. 

Other  possible  local  factors  in  abortion :  deep 
laceration  of  the  cervix,  endometritis,  etc.,  it 
is  obvious  must  be  remedied  before  pregnancy. 

It  is  possible  for  the  obstetrician  to  render 
a  great  service  by  being  especially  careful  and 
thorough  in  making  his  physical  examination. 
Many  women  never  go  to  a  physician  unless  in 
pregnancy  and  his  findings  may  be  the  means 
of  correcting  many  morbid  processes  which  the 
family  physician  has  never  been  given  the  op- 
portunity to  detect. 

Diagnosis  and  Treatment — The  great  major- 
ity of  hemorrhages  during  pregnancy  are  signs 


HEMORRHAGE   IN   OBSTETRICS  103 

of  abortion  or  miscarriage,  threatened  or  inevi- 
table. Pain  is  a  concomitant  sign.  Granted 
said  signs,  if  the  physician  has  previously  di- 
agnosed a  normal  pregnancy,  it  is  better  not  to 
make  an  examination,  bnt  place  the  patient  im- 
mediately npon  treatment  for  a  threatened 
abortion.  Both  the  rectal  and  vaginal  exami- 
nations may  by  irritation  increase  the  tendency 
to  abort  and  the  vaginal  examination  increases 
the  danger  of  infection.  Concerning  infection, 
the  late  Dr.  John  B.  Mnrphy,  of  Chicago,  told 
the  story  of  his  being  called  to  a  case  of  obvious 
threatened  abortion,  placing  the  woman  npon 
treatment,  and  leaving  without  making  an  ex- 
amination. The  next  morning  he  was  met  at 
the  door  by  the  husband  who  said  that  his  serv- 
ices would  not  be  needed  as  they  had  called 
a  real  doctor  who  had  made  a  vaginal  examina- 
tion. Several  days  later  Dr.  Murphy  passed 
that  way  and  saw  crepe  upon  the  door.  The 
moral  is  apparent :  Why  take  the  chance  of  in- 
fecting the  woman,  if  it  is  not  necessary. 

Many  times  a  di:fferential  must  be  made.  In 
my  experience,  in  the  early  months  of  preg- 
nancy, the  differential  lies  between  threatened, 
inevitable  or  incomplete  abortion,  ectopic  preg- 
nancy, pus  tubes  and  ovarian  cyst;  in  later 
months,    miscarriage,    accidental    hemorrhage 


104  TALKS    ON   OBSTETRICS 

and  placenta  previa.  The  history,  symptoms 
and  signs  differentiating  these  conditions  are 
covered  in  other  Talks.  In  making  the  exami- 
nation nse  the  rectal  first  and  then  if  in  doubt 
nse  the  vaginal  examination  exercising  the 
greatest  care  in  the  aseptic  technic. 

For  purposes  of  treatment,  abortions  and 
miscarriages  are  classified  as  follows:  Threat- 
ened, complete,  incomplete  and  septic. 

Threatened  Abortion. — Up  to  the  last  mo- 
ment treat  these  cases  as  threatened  abortion. 
A  patient  may  lose  a  pint  of  blood  and  still  go 
on  to  normal  labor. 

Put  the  patient  to  bed,  give  morphin  one- 
fourth  grain  by  hypo,  or  rectal  suppository  con- 
taining powdered  opium,  grain  one,  and  bel- 
ladonna, grain  one,  to  relieve  pain  and  muscle 
spasm.  If  pain  continues,  repeat  the  supposi- 
tory every  six  hours.  Rest  in  bed  one  week 
after  the  cessation  of  bleeding.  Counsel  again 
as  to  care  in  not  overdoing  and  the  avoidance  of 
strain  especially  at  the  time  when  menstruation 
would  normally  obtain.  Make  a  complete  phys- 
ical examination  after  the  bleeding  has  ceased, 
to  see  if  there  is  any  accounting  for  the  condi- 
tion. 

If  in  spite  of  treatment,  abortion  becomes  in- 
evitable, make  no  vaginal  manipulations  ex- 


HEMORRHAGE   IN   OBSTETRICS  105 

cept  to  pack  the  cervix  and  vagina  in  case  of 
severe  hemorrhage.  Remove  packing  in  twelve 
hours,  when  the  products  of  conception  will 
usually  be  found  on  pack. 

Do  not  enter  the  uterus  after  abortion  or  mis- 
carriage, unless  continuation  of  bleeding  and  a 
patulous  cervix  make  it  evident  that  the  abor- 
tion or  miscarriage  has  not  been  complete  and 
sufficient  time  has  elapsed  to  preclude  the  prob- 
ability of  natural  expulsion  and  restitution.  If 
you  conclude  that  the  uterus  must  be  emptied 
either  use  the  gloved  finger  as  a  curette  or  use 
the  largest  dull  curette  compatible  with  intro- 
duction through  the  cervical  canal.  A  small 
curette  is  more  likely  to  furrow  the  decidua 
without  complete  removal  and  more  likely  to 
perforate  the  uterus.  After  curettage  pack  the 
uterus  with  gauze.  This  promotes  contraction 
of  the  uterus,  inhibits  bleeding  and  upon  re- 
moval in  twelve  to  twenty-four  hours,  small 
particles  of  decidua  possibly  remaining  will 
most  likely  come  away  with  the  gauze.  If  there 
is  any  question  as  to  the  asepsis,  do  not  pack 
the  uterus. 

If  dealing  with  septic  abortion,  put  the  pa- 
tient in  the  Fowler  position,  ice  bag  on  hypo- 
gastrium,  give  ergot  by  mouth  or  hypo,  fresh 
air  and  sunlight,  forced  feeding  and  tonics. 


106  TALKS   01^   OBSTETRICS 

Do  not  curette.  By  so  doing  the  leucocytic 
barrier  may  be  broken  down  with  resulting  in- 
crease in  danger  of  general  sepsis.  This  rule 
must  be  abrogated  in  the  face  of  severe  bleed- 
ing. Light  blunt  curettage  may  here  be  insti- 
tuted, care  being  taken  to  interfere  as  little  as 
possible  with  a  possible  leucocytic  barrier,  and 
always  remembering  that  these  septic  uteri  are 
extremely  soft  and  easy  to  perforate.  In  all 
cases  be  sure  that  the  cervical  canal  is  allowing 
sufficient  drainage. 

If  infection  localizes  in  the  pelvis  with  in- 
duration, do  not  incise  unless  definite  fluctua- 
tion is  present.  Failure  to  wait  for  fluctua- 
tion is  a  frequent  error. 

In  cases  of  miscarriage  where  instrumenta- 
tion is  admitted  or  suspected  and  signs  of  se- 
vere sepsis  are  present,  with  the  delivery  of  the 
fetus  not  imminent,  the  best  results  are  ob- 
tained by  dilatation  of  the  cervix  and  extrac- 
tion. Here,  emptying  of  the  uterus  reduces  its 
size,  and  the  contraction  aided  by  ergot  tends 
to  close  the  avenues  through  which  the  infection 
may  gain  entrance  and  the  leucocytic  barrier 
has  a  smaller  area  to  cover.  Eapid  recovery 
usually  follows  this  drainage.  Such  a  proce- 
dure is  often  made  imperative  in  missed  abor- 
tion followed  by  toxemia  or  infection. 


HEMORRHAGE   IK    OBSTETRICS  107 

Before  closing  let  me  bring  to  your  attention 
the  subject  of  miscarriage  or  premature  labor 
on  or  about  the  seventh  month  when  the  vi- 
ability of  the  child  is  probable.  Treat  these 
cases  by  rest  in  bed  and  elevation  of  the  foot 
of  the  bed,  using  morphin  with  great  caution. 
Be  especially  careful  in  your  use  of  morphin,  if 
the  premonitory  signs  of  increased  dark  vaginal 
discharge  have  been  in  evidence  for  several 
days  prior  to  the  accession  of  pronounced  signs 
of  premature  labor.  This  vaginal  discharge 
generally  presages  changes  in  the  decidua 
making  premature  delivery  inevitable  and 
if  morphin  is  used,  a  probable  viable  child  may 
succumb  upon  birth  to  depression  of  the  re- 
spiratory center.  One  should  be  as  certain  as 
possible  that  the  birth  is  not  imminent  and  if 
uncertain  only  small  doses  should  be  used. 


CHAPTER  IV 
HEART  LESIONS  AND  TUBERCULOSIS 

Heart  lesions  and  tnbercnlosis  are  the  cause 
of  about  seven  per  cent  of  the  maternal  deaths 
in  present  day  obstetrics.  I  will  merely  men- 
tion some  of  the  other  possible  remaining 
causes ;  such  as,  diabetes,  carcinoma,  embolism, 
pneumonia,  etc. 

I  believe  that  all  pregnant  women  with  heart 
lesions  or  who  have  had  active  tuberculosis, 
should  have  the  best  counsel  obtainable  to 
decide  the  question  as  to  the  advisability  of 
therapeutic  abortion.  In  the  cases  with  heart 
lesions  that  have  given  serious  symptoms  and 
signs  of  decompensation,  especially  in  the  near 
past,  or  at  the  time  give  even  minor  evidences 
of  decompensation  under  normal  exertion,  and 
in  all  cases  with  active  tuberculosis  or  with 
lesions  that  have  been  active  within  two  years 
I  side  with  those  of  my  consultants  who  advise 
therapeutic  abortion  before  the  fifth  month.  I 
do  this  because  of  the  apparent  jeopardy  and 
the  mortality  in  these  cases,  because  of  the  un- 
certainty of  all  such  cases,  and  in  spite  of  the 

108 


HEART   LESIONS   AND   TUBERCULOSIS  109 

fact  that  many  patients  will  refuse  the  advice 
and  will  possibly  pass  through  pregnancy  and 
labor  without  serious  untoward  symptoms. 

It  will  aid  to  know  the  relative  seriousness  of 
various  heart  lesions  and  apply  this  knowledge 
to  the  extent  of  the  lesion  of  the  case  in  hand, 
it  will  aid  the  judgment  to  go  into  all  the  past 
history  minutely  and  seek  for  all  the  past  signs 
and  symptoms  of  decompensation,  and  to  es- 
timate the  present  reserve  strength  of  the  heart 
by  various  tests,  but  in  the  final  analysis  of 
each  case  results  show  that  even  a  fairly  defi- 
nite prognosis  is  hard  to  give.  I  must  admit 
that  fortified  with  literature,  with  discussions 
with  other  men  concerning  their  observations, 
with  actual  experience  of  my  own  cases,  and 
with  all  the  best  consultation  that  a  patient 
can  afford,  I  approach  each  case  with  no  assur- 
ance as  to  its  outcome. 

The  same  applies  to  tuberculous  patients. 
In  tuberculosis  I  do  not  necessarily  mean  the 
immediate  outcome,  but  the  later  effect  upon 
the  mother,  and  I  am  here  referring  to  those 
patients  who  either  have  active  lesions  or  who 
have  had  active  lesions  within  the  past  two 
years. 

Needless  to  say  that  after  giving  a  serious 
prognosis  we  are  often  agreeably  surprised  at 


110  TALKS   01^   OBSTETRICS 

the  result  and  onr  opinion  is  held  more  or  less 
in  contempt  by  the  family  after  a  most  normal 
and  happy  outcome. 

Do  not  be  misled  by  these  cases,  however,  and 
remember  that  a  man  should  not  urge  a  risk 
that  he  would  not  advise  in  his  own  family.  It 
seems  to  me  that  in  fev/  other  obstetric  prob- 
lems is  judgment  more  liable  to  error.  Always 
have  consultation  in  these  cases  irrespective 
of  whether  you  favor  therapeutic  abortion  or 
not.  It  goes  without  saying  that  no  man  should 
perform  a  therapeutic  abortion  in  any  condition 
until  his  opinion  as  to  its  necessity  has  been 
corroborated  by  at  least  two  men  of  unques- 
tioned professional  standing. 

As  to  the  treatment :  In  addition  to  medicinal 
treatment  and  general  measures  throughout 
pregnancy,  all  special  obstetric  treatment 
should  aim  to  make  these  labors  as  easy  for  the 
patient  as  possible,  and  all  aids  to  delivery 
should  be  used,  according  to  conditions  and 
judgment,  that  will  result  in  the  least  strain 
and  shock  to  the  patient,  such  as  assistance  by 
forceps,  version  or  what  not.  These  are  two  of 
the  general  conditions  that  may  add  indications 
for  the  imperative  need  for  interference. 

In  tuberculosis,  I  doubt  the  advisability  of  in- 
ducing labor  after  the  fifth  month.     The  end 


HEART   LESIONS   AND   TUBERCULOSIS  111 

result  will  be  questionably  different  from  labor 
at  term,  helped  by  every  aid  at  our  command 
if  necessary.  It  may  result  more  disastrously. 
In  heart  lesions,  on  the  other  hand,  decom- 
pensation may  make  an  induction  after  the  fifth 
month  imperative.  All  things  being  equal,  how- 
ever, I  believe  that  labor  at  term  will  give  as 
good  results  as  the  premature  induction  of 
labor  for  other  than  imperative  symptoms  of 
decompensation. 


CHAPTER  V 
FOECEPS 

The  obstetric  forceps,  mthout  which  few 
men  would  care  to  practice  obstetrics  today, 
a  blessing  to  humanity  when  used  with  discrimi- 
nation, like  all  other  good  things  can  become 
a  curse  if  used  indiscriminately,  and  this 
curse  makes  itself  manifest  in  the  mother  by 
fatal  hemorrhage  or  shock  and  by  frequent 
unnecessary  sepsis,  invalidism  and  preparation 
for  subsequent  surgical  operations;  and  in  the 
child  by  great  increase  in  the  percentage  of 
mortality  and  injury.  In  any  large  clinic 
hardly  a  week  passes  in  which  some  woman 
does  not  present  herself,  either  terrified  at  the 
thought  of  having  to  pass  through  another 
labor  or  to  obtain  treatment  for  injuries  sus- 
tained at  a  previous  labor  and  giving  a  history 
much  like  the  following:  At  the  birth  of  her 
first  child,  after  being  in  labor  for  three  or  four 
hours,  during  which  time  several  vaginal  ex- 
aminations were  made,  her  physician  at  first 
thought  that  the  baby  would  have  to  be  turned, 
but  decided  finally  to  use    forceps.     She   was 

112 


FORCEPS  113 

told  that  it  was  a  very  difficult  delivery.  She 
was  delivered  of  an  injured  or  dead  child,  suf- 
fered severe  lacerations  that  required  many 
stitches,  and  had  a  protracted  puerperium  ac- 
companied by  chills  and  fever.  Since  this  labor 
she  has  never  felt  well.  On  physical  examina- 
tion the  following  findings  are  obtained :  Badly 
lacerated  perineum,  cystocele  and  rectocele, 
deep  tears  in  the  cervix,  and  pelvic  adhesions 
the  results  of  previous  pelvic  infection.  What 
facts  obtained  in  her  history  and  physical  ex- 
amination would  lead  one  to  suspect  that  for- 
ceps might  not  have  been  necessary  in  this 
case?  Measurements  of  the  pelvis,  both  inter- 
nal and  external,  show  that  she  has  a  large 
roomy  pelvis  with  no  inlet  or  outlet  contraction 
and  we  find  upon  inquiry  that  her  child  had  not 
been  unusually  large.  "When  one  considers  that 
the  average  length  of  a  first  labor  is  eighteen 
hours,  the  necessity  for  using  forceps  at  the 
fourth  hour,  though  possible,  is  rather  doubtful. 
The  extremely  deep  tear  in  the  cervix  would 
lead  one  to  suspect  that  dilatation  of  the  cervix 
had  been  rapid  and  forcible  rather  than  slow 
and  gentle,  which  latter  method  is  not  likely  to 
result  in  deep  tears.  We  are  even  led  to  sus- 
pect that  the  forceps  may  have  been  applied 
before  the  cervix  was  completely  dilated.    From 


114  TALKS   ON   OBSTETRICS 

the  fact  that  version  was  considered,  we  are 
led  to  suspect  that  forceps  were  applied  to  a 
floating  head  or  that  the  accoucheur  did  not 
recognize  a  normal  position  with  an  engaged 
head.  That  infection  ensned  would  point  to  a 
slip  in  technic,  bnt  granting  the  best  asepsis, 
it  shows  the  danger  of  any  vaginal  manipula- 
tion and  instrumentation.  This  is  only  one  of 
many  histories  suggesting  the  indiscriminate 
use  of  forceps. 

In  the  face  of  textbook  expositions  and  pres- 
ent day  clinical  teaching  it  should  not  be  neces- 
sary here  to  go  into  the  minutise  of  aseptic  tech- 
nic, but  granting  the  most  careful  personal 
asepsis  and  aseptic  preparation  of  the  patient, 
two  dangerous  tendencies  are  brought  to  my 
attention  every  day;  first,  the  tendency  to 
place  too  much  confidence  in  antisepsis;  and 
second,  the  tendency  to  forget  the  fact  that  the 
anatomy  of  the  vulva  and  the  vagina  makes 
it  almost  impossible  to  count  on  thorough  asep- 
sis. Men  forget  that  when  we  enter  the  vagina, 
though  we  do  so  by  sight  and  avoid  all  other 
contact,  we  are  still  facing  the  danger  of  carry- 
ing virulent  bacteria  from  the  lower  to  the  up- 
per part  of  the  vagina  or  into  the  uterus  itself. 
Not  only  should  we  perfect  ourselves  in  the 
best  methods,  but  we  should  remember  the  f alii- 


FORCEPS  115 

bilities  of  the  best  technic.  In  our  fight  against 
bacteria  we  should  not  become  too  confident  of 
onr  own  prowess.  General  surgeons  have  long 
since  reached  this  attitude  in  regard  to  the 
probing  of  wounds.  No  general  surgeon,  wor- 
thy of  the  name,  would  thrust  his  hand  or  an 
instrument  the  length  of  an  obstetric  forceps 
blade  across  a  possible  area  of  infection  into 
the  depths  of  a  wound,  unless  for  the  most  ur- 
gent indications.  Men  frequently  ask  me  how 
it  is  possible  that  this  danger  of  sepsis  can  be 
so  imminent  when  they  have  read  in  this  book 
or  that  that  so  and  so  uses  forceps  in  nearly 
one-third  of  his  cases  or  one-fifth  as  the  case 
may  be,  and  reports  excellent  results.  Do  not 
allow  yourselves  to  be  overconfident  because 
some  of  our  ablest  obstetricians  use  forceps  in 
a  high  percentage  of  their  cases.  Remember 
that  they  get  a  relatively  greater  number  of 
difficult  cases  than  the  average  man,  that  their 
clientele  is  made  up  of  a  higher  percentage  of 
oversensitive,  neurotic  women,  weakened  by 
luxury,  which  will  necessarily  increase  the  fre- 
quency of  indications  for  the  application  of  for- 
ceps ;  and  do  not  forget  that  not  only  are  these 
men  especially  skilled  in  the  use  of  forceps  and 
exceptionally  well-trained  and  careful  in  their 
aseptic  technic,  but  that  they  work  under  the 


116  TALKS   ON   OBSTETRICS 

best  conditions  that  science  and  money  can  ob- 
tain and  with  the  most  skilled  and  reliable  as- 
sistants. 

Now  and  then  you  will  hear  a  man  advocate 
the  early  nse  of  forceps  to  hasten  delivery  in 
the  speciously  creditable  attempt  to  relieve 
women  of  pain.  As  a  sole  indication,  surely 
this  is  an  error  of  judgment  in  the  face  of  pres- 
ent day  methods  of  obtaining  the  same  result 
without  danger.  The  judicious  use  of  chloral 
and  morphin,  if  absolutely  necessary  in  the 
early  stage  of  labor,  and  the  use  of  nitrous 
oxide  gas  and  oxygen,  administered  by  an  ex- 
pert in  the  latter  part  of  labor  (may  begin  gas 
when  the  cervical  canal  is  obliterated  and  the 
external  os  dilated  to  the  size  of  a  dollar),  to- 
gether with  the  judicious  use  of  pituitrin  (three 
to  five  minims  in  repeated  doses  hypodermic- 
ally),  in  the  second  stage  of  labor  if  no  real  ob- 
struction exists,  will  permit  of  normal  delivery 
in  most  cases  with  a  minimum  of  pain,  no  dan- 
ger of  infection,  and  less  danger  of  laceration 
than  if  forceps  were  used.  Certainly  the  judi- 
cious use  of  morphin  and  pituitrin  need  not  be 
elaborated,  as  medical  literature  is  replete  with 
advisory  articles  on  this  subject.  In  relation 
to  the  use  of  chloroform  in  obstetrics  it  is  well 
to  keep  in  mind  the  danger  of  delayed  chloro- 


FOECEPS  117 

form  poisoning.    Never  use  it  in  cases  giving 
signs  of  toxemia. 

The  greater  a  man's  knowledge  and  experi- 
ence the  more  exacting  and  searching  becomes 
his  zeal,  in  the  interests  of  both  mother  and 
child,  in  trying  to  eliminate  the  necessity  for 
the  nse  of  forceps.  In  the  same  measure,  how- 
ever, does  his  zeal  increase  in  searching  for 
and  recognizing  immediately,  imperative  indi- 
cations for  their  use. 

In  the  nse  of  forceps  two  mistakes  stand  out 
conspicuously,  spelling  disaster  in  many  in- 
stances; namely,  the  attempts  to  deliver  by 
forceps  when  the  cervix  is  not  fully  dilated  or 
potentially  so,  and  the  attempts  to  deliver  a 
child  by  applying  forceps  to  a  floating  head. 
Outside  of  the  danger  of  trauma  to  mother  and 
child  these  procedures  frequently  mean  the  sub- 
sequent substitution  of  other  measures  to  con- 
summate delivery  with  increased  danger  of 
sepsis  in  proportion  to  the  increased  number  of 
manipulations  and  the  number  and  extent  of 
the  lacerations. 

In  relation  to  dilatation  of  the  cervix,  give 
Nature  and  time  a  good  chance  and  then  if  nec- 
essary use  bags  to  complete  the  dilatation,  but 
do  not  attempt  to  deliver  by  forceps  with  an 
xmdilated  cervix. 


118  TALKS   ON   OBSTETRICS 

In  relation  to  a  floating  head,  if  after  abdom- 
inal manipulation  and  the  assumption  of  the 
Walcher  position  the  head  fails  to  engage,  bet- 
ter by  far  do  a  podalic  version  if  it  is  possible 
and  deliver  by  breech  than  apply  forceps  to 
a  floating  head  and  attempt  to  deliver.  Here 
use  high  forceps  with  craniotomy  if  necessary, 
only  as  a  last  resort.  If  absolute  dispropor- 
tion exists  between  passage  and  passenger  ac- 
counting for  the  nonengagement  of  the  head, 
the  child  is  alive  and  we  can  be  sure  of  the 
previous  nonintroduction  of  infection  by  vagi- 
nal examinations,  a  selective  Csesarean  is  indi- 
cated. Such  cases  bring  home  the  value  of  the 
routine  rectal  instead  of  the  routine  vaginal 
examination.  If  sepsis  exists  or  the  child  is 
dead,  podalic  version  if  possible  and  crani- 
otomy if  necessary,  is  indicated  in  the  interest 
of  the  mother. 

Having  assured  oneself  as  far  as  possible 
by  mensuration  that  the  passage  offers  no  in- 
surmountable barrier  to  the  birth  of  the  pas- 
senger, with  the  cervix  completely  dilated  and 
the  head  firmly  engaged  and  in  a  position  al- 
lowing of  delivery,  certain  indications  must 
dictate  the  need  for  forceps.  Under  the  above 
conditions  of  passage  and  passenger  if  the  child 
is  advancing  and  shows  no  evidences  of  danger- 


FORCEPS  119 

Oils  pressure  such  as  weak  irregular  heart 
sounds  of  markedly  increased  or  decreased  fre- 
quency, especially  the  latter,  and  the  mother 
shows  no  local  signs  requiring  quick  action 
such  as  hemorrhage,  contraction  ring  reaching 
to  t^e  umbilicus,  pressure  edema  or  bladder 
paralysis,  no  general  signs  and  symptoms  of 
hemorrhage  or  exhaustion,  such  as  weak  rapid 
pulse,  etc.,  and  no  constitutional  condition  ex- 
ists bespeaking  aid,  such  as  severe  heart  or 
kidney  disease,  eclampsia  or  tuberculosis,  the 
use  of  forceps  is  contraindicated.  The  slow 
delivery  by  tending  to  limit  lacerations  opens 
up  fewer  channels  for  the  admission  of  infec- 
tion and  noninterference  introduces  no  infec- 
tion. 

Toward  those  men  who  say  that  they  have 
used  routine  vaginal  examinations  and  forceps 
for  years  and  years  and  never  had  an  untoward 
result,  one  can  only  show  that  deference  due 
also  to  the  men  whose  cases  never  show  a  lacer- 
ation. Their  technic  must  be  phenomenal. 
Statistics,  however,  might  modestly  suggest  the 
added  element  of  good  fortune.  Surely  they 
will  admit  that  in  general  the  obstetrician  who 
guards  his  patient  against  the  importunities 
for  or  actual  attempts  at  meddlesome  inter- 
ference shows   greater  wisdom  and  prowess 


120  TALKS    ON    OBSTETRICS 

than  he  who  hastens  to  a  display  of  his  technic 
no  matter  how  faultless  or  successful  it  has 
proved  in  the  past. 

Before  applying  the  forceps,  run  over  in  your 
mind  the  mnemonic  originating  with  Dr.  S.  E. 
Moore,  one  time  Teaching  Fellow  in  Obstetrics 
at  the  University  of  Minnesota.  This  is  called 
the  A.B.C.'s  of  forceps  application.  Each  letter 
stands  for  two  things  to  be  done.  Let  A  stand 
for  Application  and  Amnion.  In  other  words, 
before  attempting  to  apply  the  forceps  deter- 
mine the  position  of  the  head,  lock  the  forceps, 
hold  them  up,  and  figure  out  the  application, 
and  be  sure  that  the  membranes  are  ruptured. 
Let  B  stand  for  Bladder  and  Bowel.  See  to  it 
that  they  are  emptied  before  attempting  to  de- 
liver by  forceps.  Let  C  stand  for  Cervix  and 
Cord.  Be  sure  that  the  cervix  is  dilated  and 
that  you  pass  within  the  cervix  in  the  introduc- 
tion of  the  blades  and  be  sure  that  a  prolapsed 
cord  is  not  within  the  grasp  of  the  forceps. 
This  is  a  very  clever  and  helpful  nmemonic. 

Do  not  attempt  to  apply  the  forceps  until  the 
patient  is  well  under  an  anesthetic. 

In  delivery  take  plenty  of  time  and  do  not 
think  that  you  must  deliver  the  baby  with  one 
pull.  In  beginning  the  gradual  traction  with 
the  right  hand,  keep  the  fingers  of  the  left  hand 


FORCEPS  121 

on  the  head  to  see  that  the  forceps  are  not  slip- 
ping. Let  the  pull  be  slow  and  steady  and  un- 
lock the  forceps  at  from  one-half  to  one  minute 
intervals.  Let  the  progress  simulate  as  nearly 
as  possible  normal  delivery,  for  the  sake  of 
both  baby  and  mother.  As  soon  as  the  head  is 
under  control,  remove  the  forceps  and  deliver 
as  in  a  normal  delivery. 


CHAPTER  VI 
PODALIC  VERSION 

One  of  the  most  frequent  questions  in  out- 
patient teaching  is,  ^^What  are  the  indications 
for  podalic  version?" 

Before  going  into  details,  I  would  repeat  a 
statement  made  by  an  old  country  practitioner 
who  had  over  twenty-three  hundred  obstetric 
cases  to  his  credit.  *  ^In  the  face  of  abnormality 
or  perplexity  never  forget  to  weigh  the  possible 
benefits  of  version.  It  has  brought  me  more 
success  in  difficulties  than  all  other  obstetric 
procedures  barring  medium  and  low  forceps. 
Never  forget  podalic  version. ' '  Make  this  per- 
sonal and  let  it  always  ring  in  your  ears  and 
see  if  you  do  not  have  many  opportunities  for 
feeling  grateful  for  this  advice. 

Let  us  first  take  up  the  contraindications  to 
an  attempt  at  version: 

1.  Where  our  examinations  show  that  the 
marked  disproportion  between  the  pelvis  and 
the  fetal  head  will  not  allow  of  the  delivery  of 
the  after  coming  head.    (We  are  here  consider- 

122 


PODALIC   VERSTON  123 

ing  the  case  of  a  live  child  where  craniotomy  is 
not  indicated  in  the  interest  of  the  mother.) 

2.  When  the  head  is  firmly  engaged.  (Deep 
anesthesia  may  permit  disengagement.) 

3.  When  a  high  contraction  ring  exists,  with 
a  thick  upper  uterine  segment  and  a  thin 
stretched  out  lower  segment.  The  version  is 
here  likely  to  cause  rupture  of  the  uterus. 

4.  When  the  amniotic  fluid  has  long  been 
drained  away  and  the  uterus  is  firmly  con- 
tracted around  the  child.  Here  again  we  are 
running  a  great  chance  of  rupture  of  the  uterus. 

Podalic  version  should  immediately  suggest 
itself  in  oblique  and  transverse  presentations. 

Version  is  a  possible  resource  in  face,  brow 
and  persistent  occiput  posterior  positions  with 
arrest  at  the  inlet. 

Consider  version  in  all  cases  where  there  is 
no  absolute  disproportion  between  the  pelvis 
and  fetal  head  and  where  the  presenting  part 
will  not  engage.  In  such  a  case  do  not  consider 
high  forceps,  except  as  a  final  resort,  with  per- 
haps craniotomy.  I  am  of  the  personal  opinion 
that  there  is  rarely  a  case  in  obstetrics  in  which 
high  forceps  might  be  used  on  a  floating  head 
that  would  not  better  be  delivered  in  some  other 
way. 

Consider  version  to  hasten  deliverv    as    in 


124  TALKS    ON    OBSTETRICS 

eclampsia  and  premature  separation  of  the  pla- 
centa; as  a  means  of  tamponade  in  placenta 
previa;  when  prolapsed  cord  will  not  stay 
replaced;  and  in  deformed  pelves  of  a  minor 
variety  where  the  internal  conjugate  is  not 
below  8  cm.  In  such  cases  if  previous  labors 
have  proved  disastrous  and  resulted  in  a 
dead  child,  and  abdominal  Caesarean  section  un- 
der selective  conditions  can  be  performed,  I 
would  prefer  it  to  version.  This  applies  also 
to  primipara  in  which  the  fetal  mortality  of 
version  is  high.  I  am  stating  conditions  in 
which  it  may  be  considered  and  perchance  sur- 
roundings may  make  it  the  measure  of  choice 
or  necessity. 

Version  is  indicated  in  those  cases  which 
would  demand  a  Csesarean  were  it  not  for  in- 
fection or  a  dead  child.  Here  delivery  may  be 
consummated  if  necessary  by  craniotomy. 

Before  doing  a  podalic  version  be  sure  that 
the  bladder  and  rectum  are  emptied  and  that 
the  patient  is  well  relaxed  under  the  anesthetic. 

In  conclusion  let  me  mention  several  prac- 
tical points  in  the  technic  where  I  have  seen 
men  fall  down.  Be  sure  that  you  are  inside  of 
the  amnion.  Be  sure  that  you  grasp  a  foot  and 
not  a  hand.  (The  heel  is  the  distinguishing 
feature.)    Grasp  the  anterior  foot.    If  the  head 


PODALIC   VERSION  125 

obstructs  in  pulling  down  the  foot,  abdominal 
manipulation  with  the  free  hand  will  aid  in 
pushing  the  head  to  one  side.  Do  not  withdraw 
your  hand  from  inside  the  uterus  until  you 
have  completed  the  maneuver,  no  matter  how 
much  thinking  you  have  to  do  or  how  many  at- 
tempts you  have  to  make  before  you  have  suc- 
ceeded in  drawing  down  the  foot.  It  is  obvious 
that  the  withdrawal  and  reinsertion  of  the  hand 
will  increase  the  chances  of  infection.  Draw 
the  foot  down  with  the  heel  facing  the  operator 
so  that  the  fetal  back  will  face  the  front.  See 
that  the  cord  is  not  prolapsed  before  withdraw- 
ing hand. 


CHAPTER  VII 
PROLAPSE  OF  THE  CORD 

Thougli  this  complication  is  less  likely  to  oc- 
cur when  a  normal  presenting  part,  in  normal 
position,  is  engaged  snugly  in  the  pelvis  before 
the  advent  of  labor,  always  seek  for  it  in  every 
labor  in  making  yonr  rectal  examinations. 

Make  it  a  rnle  to  examine  all  patients  as  soon 
as  possible  after  the  rupture  of  the  membranes. 
The  out  rushing  fluid  may  carry  the  cord  with  it. 
If  it  is  diagnosed  before  the  rupture  of  the 
membranes,  keep  the  hips  elevated  until  the 
membranes  rupture  and  the  part  is  engaged. 

If,  after  rupture  of  the  membranes,  the  cord 
is  found  to  be  prolapsed,  do  not  interfere  if  the 
cord  does  not  pulsate  and  the  fetal  heart  sounds 
are  absent  unless  the  complete  dilatation  of  the 
cervix  will  allow  of  rapid  delivery  by  forceps 
or  breech  extraction  and  you  feel  sure  that  the 
child  gave  evidences  of  vigor  only  a  short  time 
before. 

If  the  fetal  heart  sounds  are  present  or  the 
pulsation  of  the  cord  can  be  made  out,  try  the 
following  procedures:  With  the  woman  in  the 

126 


PROLAPSE   OF   THE   CORD  127 

knee-chest  or  Trendelenburg  position  try  to 
push  back  the  cord  with  the  finger.  In  vertex 
positions  it  is  sometimes  possible  to  hang  the 
cord  on  the  ear  and  thns  keep  it  back.  If  re- 
placement by  the  finger  fails,  you  may  try  the 
technic  of  replacing  mth  a  catheter  which  has 
a  tape  drawn  through  the  eye.  If  the  cervix  is 
completely  dilated  and  the  head  engaged,  after 
replacement  of  the  cord,  apply  forceps  and 
draw  the  head  being  careful  not  to  include  the 
cord  in  the  grasp  of  the  forceps.  If  the  cervix 
is  not  completely  dilated,  and  the  head  is  either 
not  engaged,  or  not  so  firmly  engaged  but  that 
it  may  be  pushed  back,  and  the  cord  will  not  re- 
main in  place  after  reposition,  do  a  version  and 
deliver  by  breech.  If  the  breech  presents  in  the 
first  place  pull  down  a  foot  and  thus  tampon 
the  cervix  snugly  after  replacing  the  cord.  It 
may  be  necessary  to  dilate  the  cervix  with  a 
bag  before  any  maneuver  is  possible. 

I  have  made  it  a  rule  not  to  temporize  mth 
this  complication  and  if  I  have  the  least  diffi- 
culty in  keeping  the  cord  replaced,  where  for- 
ceps cannot  be  used,  I  pull  do^vn  a  foot  as  soon 
as  possible  and  deliver  by  breech.  It  has  been 
found  that  where  forceps  cannot  be  used,  the 
delivery  by  breech  gives  only  one-half  the  fetal 
mortality  of  the  vertex  delivery. 


128  TALKS   ON   OBSTETRICS 

All  things  being  equal,  the  earlier  the  diag- 
nosis the  greater  the  success. 

Do  not  forget  to  examine  for  a  prolapsed  cord 
as  soon  as  possible  after  the  rupture  of  the 
membranes. 


CHAPTER  VIII 
BEEECII  DELIVERY 

A  goodly  share  of  men  are  likely  to  be  over- 
perturbed  in  the  presence  of  a  breech  presenta- 
tion, and  if  not  well  versed  in  the  rectal  and 
abdominal  examinations  and  imbned  with  a 
saving  fear  of  the  vaginal  examination,  the  life 
of  the  mother  is  more  likely  to  be  endangered 
by  unnecessary  vaginal  examinations  at  fre- 
quent intervals  than  by  the  results  of  the  deliv- 
ery itself. 

Although  the  breech  is  not  an  ideal  dilator, 
in  most  instances  it  succeeds  very  well  if  you 
give  it  time.  Do  not  be  anxious.  The  danger 
lies  in  the  increased  mortality  of  the  child  and 
this  danger  does  not  usually  arise  until  the 
cervix  is  dilated  and  the  child  has  passed 
through  the  cervix  as  far  as  the  navel.  In  dry 
labors,  of  course,  the  child  may  be  in  danger  at 
an  earlier  period.  Here  Vorhees  bags  may 
take  the  place  of  the  membranes  in  dilating  the 
cervix. 

The  average  breech  will  need  no  interference. 
Count  on  a  longer  delivery  than  in  a  vertex 

129 


130  TALKS   ON   OBSTETKICS 

case,  which  should  average  eighteen  hours 
for  a  primipara  and  from  twelve  to  fourteen 
for  a  multipara.  Do  not  be  perturbed  if 
the  breech  case  lasts  longer  than  this  so  long  as 
the  child  and  mother  are  doing  well.  The  prog- 
ress of  dilatation  of  the  cervix  and  descent  of 
the  breech  can  be  well  made  out  by  rectal  exam- 
ination; and  the  mother's  pulse,  and  observa- 
tion for  the  contraction  ring  and  auscultation 
of  the  fetal  heart  will  keep  one  in  close  touch 
with  the  condition  of  mother  and  child. 

Be  sure  to  have  someone  present  who  can 
push  down  on  the  af tercoming  head  through  the 
abdomen  to  aid  when  you  are  using  the  Smellie- 
Veit  maneuver. 

Only  five  minutes  should  elapse  between  the 
passage  of  the  child's  navel  through  the  cervix 
and  the  birth  of  the  head.  Have  tubs  ready  for 
resuscitation. 

Don't  forget  to  keep  the  child's  back  rotated 
to  the  front  and  to  see  that  the  arms  are  not 
caught  behind  the  head  when  attempting  to  de- 
liver the  shoulders. 

Keep  the  exposed  portion  of  the  child  cov- 
ered with  a  moist  warm  sterile  towel  to  prevent 
stimulation  of  the  breathing  before  the  head  is 
born. 

If  the  breech  becomes  impacted  and  the  ad- 


BKEECH   DELIVERY  131 

vance  stops,  we  may  push  up  the  breech  and 
pull  down  a  foot,  which  is  possible  of  accom- 
plishment in  a  great  majority  of  instances.  To 
prevent  this  possibility  of  an  impacted  breech, 
which  occurs  more  often  in  primiparse  than  in 
multiparse ;  in  a  primipara  when  a  footling  pre- 
sents, when  the  cervix  is  sufficiently  dilated  to 
grasp  the  foot,  pull  the  latter  do\\m.  When  the 
foot  is  pulled  down,  allow  ample  time  for  the 
complete  dilatation  of  the  cervix  before  at- 
tempting extraction.  If  you  do  not,  the  cervix 
will  contract  around  the  neck  and  prevent  the 
quick  delivery  of  the  head. 

In  impacted  breech  where  the  breech  cannot 
be  pushed  back  and  a  foot  drawn  down,  the 
procedures  in  order  of  choice  are:  Finger  in 
the  groin,  fillet  around  the  groin,  and,  as  a  last 
resource,  Braun's  hook.  In  these  procedures 
fractures  are  common  even  with  the  greatest 
care.    We  are  seldom  called  upon  to  use  them. 

Most  breech  deliveries  are  consummated 
without  the  advent  of  complications.  The  main 
considerations  are  to  watch  the  condition  of 
mother  and  child  as  in  any  other  delivery,  and 
to  work  up  the  technic  of  delivery  from  the  time 
of  the  birth  of  the  navel,  until  you  are  sure  of 
precision  and  rapidity  combined  with  gentle- 
ness to  preclude  injury  to  the  child. 


CHAPTER  IX 
DELIVEEY  OF  TAVINS 

During  the  delivery  of  twins  the  question  is 
often  asked,  '  ^  Should  we  interfere  in  the  deliv- 
ery of  the  second  child  and  if  so  what  are  the 
indications?"  I  believe  that  we  should  never 
interfere  unless  we  find  an  abnormal  presenta- 
tion of  the  second  child,  a  prolapsed  cord,  or 
some  indication  on  the  part  of  mother  or  child 
demanding  interference  as  in  any  other  de- 
livery. 

After  the  birth  of  the  first  twin  sever  the 
cord  between  two  cord  ties  as  always,  and  then 
treat  the  second  delivery  just  as  you  would  in 
any  delivery.  Make  sure  of  the  normality  of 
the  presentation  and  position  and  the  absence 
of  a  prolapsed  cord.  Watch  carefully  for  hem- 
orrhage from  the  placenta  and  watch  the  fetal 
heart  sounds  at  frequent  intervals  in  order  to 
detect  weakness  at  the  earliest  possible  mo- 
ment.   If  all  is  well,  leave  the  case  alone. 

The  great  majority  of  cases  will  need  no  in- 
terference and  where  it  is  indicated  speedy  and 
proper  interference  mil  in  most  cases  be  suc- 

132 


DELIVERY   OF   TWII^S  133 

cessful.  I  do  not  believe  we  are  v^arranted  in 
artificially  rupturing  the  second  bag  of  waters 
and  doing  a  version  and  breech  extraction  ac- 
cording to  a  time  schedule  simply  because  indi- 
cations might  arise  to  call  for  interference 
later.  Such  a  procedure  may  be  open  to  argu- 
ment under  ideal  conditions  where  the  most 
perfect  asepsis  may  be  assured.  Personally  I 
do  not  believe  in  it  even  under  these  conditions. 
But  surely  such  a  procedure  is  not  warranted 
under  the  conditions  that  confront  many  physi- 
cians in  the  country  and  poor  city  districts. 
The  danger  of  infection  is  too  great.  Granting 
careful  watching  for  indications  for  interfer- 
ence, I  do  not  believe  that  early  interference 
according  to  a  fixed  time  schedule  will  assure 
a  higher  percentage  of  uninjured  and  living 
second  babies  than  the  rule  of  not  interfering 
except  for  definite  indications. 

Many  men  seem  to  have  been  more  impressed 
in  their  studies  with  the  danger  of  interlocking 
and  other  abnormalities  than  with  the  normal- 
ity of  the  great  majority  of  twin  deliveries.  In 
all  cases  of  abnormalities  remember  the  rule, 
**Push  up  what  you  don't  want  and  pull  down 
what  you  do  want. ' ' 


CHAPTEK  X 
CESAREAN  SECTION 

This  operation  is  so  spectacular  and  thus 
seems  to  leave  such  an  indelible  impression  on 
a  student's  mind  and  the  well  selected  cases  in 
clinics  give  such  a  high  percentage  of  success 
that  from  the  remarks  of  students  it  becomes 
obvious  that  many  men  do  not  realize  the  care 
with  which  these  cases  are  selected  in  point  of 
definite  indications  for  Csesarean  and  in  point 
of  ruling  out  risks  of  previously  introduced  in- 
fection. At  the  beginning  of  this  discussion  I 
would  like  to  emphasize  the  fact  that  where 
keen  selective  care  is  not  exercised  in  choosing 
cases  for  Csesarean  the  mortality  mil  mount  to 
tAventy-five  per  cent  or  even  higher  and  thus 
the  Cesarean  will  hold  forth  a  worse  prognosis 
than  almost  any  other  form  of  interference.  I 
am,  of  course,  speaking  in  the  interest  of  the 
mother  who  should  be  considered  before  the 
child  in  all  cases. 

With  a  live  child  the  two  absolute  indications 
for  Csesarean  are: 

134 


CESAREAN-   SECTION  135 

1.  Absolute  disproportion  between  the  pas- 
senger and  passage. 

2.  Interposition  of  pelvic  tumors,  which  in 
each  individual  case  in  consultation  have  been 
considered  as  insurmountable  obstructions. 
Eemember  that  the  great  majority  of  tumors 
will  be  passed  by  the  presenting  part  and  will 
not  prove  to  be  insurmountable  barriers. 

Concerning  the  borderline  cases  of  pelvic 
contracture  and  tumors  remember  that  in  the 
first  pregnancy  at  least  all  women  should  be 
given  a  test  of  labor.  Many  of  these  cases  are 
deceptive  and  one  will  often  be  surprised  and 
many  times  slightly  embarrassed  to  see  a  labor 
consummated  naturally  if  not  precipitately 
where  all  preparations  have  been  made  for  a 
most  probable  selective  Csesarean.  Over  enthu- 
siasm for  the  Csesarean  has  undoubtedly  re- 
sulted in  many  unnecessary  performances  of 
the  same,  as  is  sometimes  proved  by  subse- 
quent normal  deliveries.  On  the  other  hand, 
through  failure  to  make  accurate  measure- 
ments, and  careful  examinations,  many  women 
have  undoubtedly  suffered  unnecessarily  and 
many  babies  have  been  lost  because  a  Csesarean 
has  not  been  the  operation  of  choice. 

Remember  that  every  vaginal  examination 
or  instrumentation  makes  the  woman  a  poorer 


136  TALKS   ON   OBSTETRICS 

risk  for  a  subsequent  Csesarean  section.  This 
accentuates  the  great  value  of  the  rectal  ex- 
amination. Also  remember  the  great  danger 
of  placental  bacteriemia  with  subsequent  gen- 
eral sepsis  if  the  operation  is  performed 
much  over  twenty-four  hours  after  the  rup- 
ture of  the  membranes.  All  these  consider- 
ations may  make  the  choice  of  the  operation  a 
matter  of  the  nicest  judgment.  Few  men  have 
not  seen  mortalities  eventuate  because  of  fail- 
ure to  weigh  the  chances,  and  a  live  child  ob- 
tained followed  by  the  death  of  the  mother. 

In  selected  cases  of  the  complete  variety  of 
placenta  previa,  the  Csesarean  may  give  the 
highest  percentage  of  success,  but  if  the  keen- 
est judgment  is  not  used  in  choosing  these  cases 
I  feel  positive  that  the  maternal  mortality  will 
be  infinitely  greater  than  when  other  methods 
of  delivery  are  used.  The  same  holds  for  the 
few  cases  of  premature  separation  of  the  pla- 
centa where  the  urgent  need  for  immediate  de- 
livery may  seem  to  render  the  choice  of  a 
Csesarean  imperative. 

In  those  cases  of  severe  toxemia  where,  with- 
out the  definite  indication  of  pelvic  contracture, 
the  long  hard  cervix  and  imperative  indications 
for  rapid  delivery  may  make  the  operation  one 
of  possible  choice,  the  decision  is  a  very  difficult 


CiESAREAISr   SECTION  137 

one.     In  well  selected  cases  results  certainly 
make  it  justifiable. 

From  observation  of  those  instances  where 
women  conceive  for  the  first  time  late  in  life 
and  present  pelves  of  questionable  size  and  tis- 
sues of  questionable  elasticity,  and  where  in  all 
probability  it  will  be  the  only  child  they  can 
have  because  of  the  close  proximity    to    the 
probable  end  of  the  childbearing  period,  I  be- 
lieve that  the  indication  for  a  selective  Cgesa- 
rean  may  hold.    These  women  should,  of  course, 
always  be  given  a  trial  of  labor  as  it  is  well 
known  that  many  of  these  women  deliver  with- 
out trouble.    I  hesitate  to  mention  this  possible 
indication  for  Csesarean,  although  I  believe  in 
it  thoroughly,  because  unless  acted  upon  with 
the  greatest  care  and  conservatism  it  would  un- 
doubtedly result  in  much  abuse  and  great  harm. 
I  am  convinced  that  at  present  too  many  Cge- 
sareans  are  performed  unnecessarily,  but    on 
the  other  hand,  I  am  sure  that  with  greater 
care  in  pelvimetry,  discrimination  and  selective 
judgment  on  the  part  of  the  profession  in  the 
future,  this  operation  will  save  many  lives. 

In  relation  to  the  choice  between  the  vaginal 
and  the  abdominal  Csesarean,  I  believe  that  the 
former  is  justifiable  only  when  the    child    is 


138  TALKS   ON   OBSTETRICS 

small.  AYhen  the  child  is  near  term  I  have 
never  yet  seen  the  vaginal  Csesarean  performed 
that  I  haven't  been  impressed  with  the  fact 
that  from  all  appearances  it  was  a  mnch  more 
shocking  operation  for  the  mother  and  most 
certainly  increased  the  danger  to  the  child.  I 
could  never  see  why  the  abdominal  route  were 
not  the  safer  from  the  standpoint  of  asepsis. 

Consideration  of  Csesarean  section  should 
impress  the  following  obligations : 

1.  The  obligation  to  measure  every  pelvis 
carefully,  especially  the  pelves  of  primiparse 
and  those  giving  histories  of  previous  difficult 
and  disastrous  labors. 

2.  The  obligation  to  examine  for  any  tumor 
obstruction  in  every  case,  so  that  if  a  Csesarean 
is  definitely  indicated  or  proves  to  be  after  a 
trial  of  labor,  all  preparations  can  be  made  for 
its  performance  before  the  condition  of  the 
mother  or  child  contraindicates  its  use. 

3.  The  obligation  to  so  conduct  our  examina- 
tions in  labor  that  if  Caesarean  must  be  resorted 
to,  it  can  be  undertaken  without  the  fear  of 
infection  previously  introduced.  Become  ex- 
pert in  the  use  of  the  rectal  examination,  and 
do  not  use  the  vaginal  examination  except  when 
doubt  makes  it  absolutely  necessary. 


CiESAREAN   SECTION  139 

4.  The  obligation  to  remember  that  unless 
the  keenest  selective  judgment  is  used  in  choos- 
ing cases  for  Cesarean  section,  the  maternal 
mortality  will  be  higher  than  in  the  use  of  other 
accepted  methods  of  delivery. 


CHAPTER  XI 

OCCIPUT  POSTEEIOE  POSITIONS 

Do  not  be  disturbed  when  you  have  made  a 
diagnosis  of  an  occiput  posterior  position.  Sta- 
tistics show  that  eighty  per  cent  will  rotate  an- 
teriorly, if  you  but  give  them  time,  and  that 
three  out  of  every  four  of  the  remaining  twenty 
per  cent  that  remain  posterior  will  be  born  spon- 
taneously with  the  face  toward  the  symphysis. 
You  may  never  see  one  requiring  operative 
interference  because  of  the  posterior  position. 
I  do  not  say  this  to  lull  you  into  a  feeling  of 
false  security,  but  rather  to  introduce  more  calm 
to  deliberations  in  the  presence  of  an  occiput 
posterior  diagnosis.  The  most  frequent  error 
that  I  have  encountered  in  such  deliberations  is 
the  tendency  not  to  allow  sufficient  time  for  na- 
ture to  complete  the  anterior  rotation.  Be  sure 
that  you  are  dealing  with  an  absolute  arrest  or 
that  indications  call  for  imperative  procedures 
before  you  attempt  interference.  If  you  do 
not  follow  this  advice  you  are  likely  to  en- 
counter  trouble   unnecessarily  that   you  will 

140 


OCCIPUT   POSTERIOR   POSITIONS  141 

never  forget.    It  is  frequently  one  of  the  most 
difficult  situations  to  be  met  in  obstetrics. 

The  average  time  of  delivery  will  be  length- 
ened from  three  to  four  hours  by  this  position. 
Don't  forget  this,  and  give  these  women  every 
chance  in  the  world  to  deliver  naturally.  You 
will  often  be  surprised  when  you  have  just 
about  given  up  all  hope  of  natural  delivery,  to 
see  or  feel  the  head  suddenly  rotate  anteriorly 
with  subsequent  very  rapid  delivery.  I  have 
several  times  barely  finished  a  talk  on  the  diffi- 
culties of  persistent  occiput  positions  when 
the  woman  delivered,  with  perfect  ease,  a  full 
term  baby  i\ith  the  head  in  the  posterior 
position. 

What  shall  we  do,  however,  when  we  meet 
the  exceptional  case  that  imperatively  calls  for 
interference  because  of  arrest  in  the  posterior 
position?  Eealize  that  you  have  a  real  man's 
job  before  you.  Do  not  be  misled  by  the  con- 
fidence and  ease  with  which  experts  attack 
these  cases  and  accomplish  excellent  results. 
"When  you  read  that  the  Scanzoni  or  any  other 
maneuver  to  rotate  the  head  with  forceps  is 
simple,  remember  that  what  the  writer  means 
is,  that  it  is  simple  for  him.  The  average  man 
would  be  about  as  successful  as  he  would  be  if 
he  attempted  to  play  the  Beethoven  violin  con- 


142  TALKS    ON    OBSTETPvICS 

certo  after  reading  an  article  by  a  virtuoso. 
These  maneuvers  in  any  but  expert  hands  will 
kill  most  of  the  babies  and  will  either  sacrifice 
or  maim  for  life  a  good  share  of  the  mothers. 
About  the  only  time  that  the  average  man 
achieves  even  apparent  success  with  these  ma- 
neuvers is  when  the  head  would  have  rotated 
any^vay  and  would  most  probably  have  been 
born  naturally  had  he  given  nature  time. 
General  rules  of  attack  are : 

1.  Try  to  rotate  the  head  anteriorly  with  the 
hand.    Flex  the  head  at  the  same  time. 

2.  If  the  head  will  not  remain  in  an  anterior 
position  after  flexion  and  rotation,  try  a  podalic 
version,  if  there  are  no  contraindications.  Ver- 
sion in  primijparse  results  in  a  high  fetal  mor- 
tality and  may  result  in  serious  lacerations  in 
the  mother,  but  I  believe  that  in  average  hands 
it  mil  meet  with  greater  success  than  vnll  high 
forceps  manipulations.  High  forceps  may  be 
the  operation  of  necessity. 

3.  If  the  head  is  well  down  and  rotated  di- 
rectly posterior,  apply  the  forceps  with  a  pelvic 
application  as  in  the  ordinary  low  or  mid  for- 
ceps and  deliver  the  head  in  the  posterior  po- 
sition. As  three  out  of  four  of  these  posterior 
rotations  will  deliver  spontaneously  I  am  sure 


OCCIPUT   POSTERIOR   POSITIONS  143 

that  this  method  will  meet  with  the  greatest 
success. 

4.  If  the  head  remains  posterior  in  the  oblique 
diameter,  manual  rotation  or  version  is  impos- 
sible, and  if  the  aid  of  an  expert  cannot  be  ob- 
tained, make  a  pelvic  application  and  draw  the 
head  dowTi  allowing  it  to  rotate  anteriorly  or 
posteriorly  as  it  will  and  changing  the  applica- 
tion as  often  as  the  rotation  of  the  head  makes 
it  expedient.  This  is  a  difficult  procedure  at  its 
best  and  craniotomy  may  be  necessary  to  con- 
summate delivery,  but  I  feel  sure  that  it  will 
result  in  fewer  fetal  injuries  and  deaths  and 
fewer  maternal  lacerations  and  deaths  than  will 
forced  anterior  rotation  with  forceps  according 
to  any  method  in  the  hands  of  any  but  experts. 
I  believe  that  anyone  will  agree  with  me  on  this 
point  after  he  has  seen  results  of  forcible  for- 
ceps rotation  as  used  by  men  of  average  expe- 
rience. 


CHAPTER  XII 
FACE  PRESENTATION 

When  you  encounter  a  face  presentation,  if 
the  chin  points  anteriorly  leave  the  case  alone. 
In  all  probability  spontaneous  delivery  will 
take  place  though  the  labor  may  be  prolonged. 

If  the  chin  is  posterior,  as  soon  as  the  di- 
latation of  the  cervix  will  permit,  attempt 
to  convert  the  face  presentation  into  a  ver- 
tex. With  the  woman  well  relaxed  under  an 
anesthetic,  with  one  hand  in  the  vagina  flex  the 
head  by  pushing  up  on  the  chin,  while  with  the 
free  hand  you  push  down  on  the  occiput 
through  the  abdomen.  An  assistant  must  at 
the  same  time  flex  the  body  of  the  child  by 
pressing  against  the  chest  of  the  child  through 
the  abdomen.  This  is  easier  done  than  one 
would  imagine.  It  does  not  hold  forth  the  dan- 
ger of  version,  as  you  introduce  nothing  far 
into  the  uterus  to  increase  the  volume  of  the 
contents,  and  the  range  of  motion  for  the  child 
is  not  so  great  as  in  version.  It  may  thus  be 
done  with  impunity  long  past  the  time  when 
a  version  would  be  contraindicated.  After  this 
maneuver  it  is  obvious  that  a  right  mental  pos- 

144 


FACE   PRESENTATION  145 

terior  position  becomes  a  left  occiput  anterior 
position.  If  for  some  reason  you  fail  in  this 
maneuver  try  a  version,  especially  if  the  chin 
faces  directly  to  the  rear.  The  chances  of  suc- 
cess in  these  maneuvers  will  depend  directly 
upon  the  stage  of  labor  in  which  the  diagnosis 
is  made  and  the  results  emphasize  the  value  of 
careful  examinations  at  the  beginning  of  labor. 
If  in  posterior  chin  positions,  conversion 
to  the  occipito  anterior  positions  fail  and  ver- 
sion is  impossible,  the  chin  may  rotate  ante- 
riorly when  it  reaches  the  pelvic  floor.  I  have 
never  seen  a  case  that  could  not  either  be 
changed  to  a  vertex,  turned  by  podalic  version 
or  which  did  not  rotate  anteriorly  with  a  spon- 
taneous delivery  or  a  delivery  aided  by  forceps. 
In  the  event  of  the  chin  remaining  posterior, 
textbooks  tell  us  to  attempt  to  rotate  the  chin 
anteriorly  mth  the  hand  or  the  forceps.  In 
such  a  rare  contingency,  if  the  hand  rotation 
were  not  successful,  especially  where  the  chin 
points  directly  posterior,  I  doubt  if  the  slender 
chance  of  delivering  a  live  or  uninjured  baby 
by  forceps  rotation  attempted  by  any  but  the 
most  expert  would  warrant  the  infinitely  greater 
chance  of  severe  injury  to  the  mother.  I  would 
favor  craniotomy  after  the  most  careful  and 
limited  trial. 


CHAPTER  XIII 

BBOW  PRESENTATION 

The  man  who  understands  the  mechanism 
and  management  of  face  presentations  will 
know  what  to  do  with  brow  presentations. 
Both  face  and  brow  presentations  are  due  to 
conditions  either  limiting  the  normal  flexion  of 
the  fetal  head  or  franldy  favoring  extension. 
The  brow  is  the  presentation  about  midway  be- 
tween the  normal  occiput  and  the  frank  face 
presentations.  Brow  presentations  are  infre- 
quently encountered  because  by  the  time  we 
first  see  a  case  that  has  begun  labor  with  the 
brow  presenting,  it  has  either  resolved  itself 
into  a  normal  vertex  presentation  by  flexion  or 
into  a  frank  face  presentation  by  extension. 
This  fact  gives  us  a  good  hint  for  use  in  treat- 
ment ;  namely,  when  a  brow  presentation  is  di- 
agnosed early  in  labor  allow  time  for  it  to  re- 
solve naturally  into  a  vertex  or  a  face  presenta- 
tion. The  management  then  follows  the  indica- 
tions for  those  presentations. 

If  the  brow  presentation  gives  no  indication 
of  early  resolution,  try  to  convert  it  into  a  ver- 

146 


BROW   PRESENTATION  147 

tex  by  flexion  of  the  head  and  body  as  in  a 
frank  face  presentation  when  the  chin  lies  in  a 
posterior  position.  If  this  fail,  attempt  a  ver- 
sion, providing  absolute  contraindications  do 
not  exist.  We  should  see  to  it  that  we  do  not 
allow  the  brow  presentation  to  persist  to  the 
stage  when  version  would  be  contraindicated, 
without  an  attempt  at  interference.  If  the  chin 
points  or  rather  lies  anterior  and  does  not  re- 
solve into  a  face  presentation  with  the  chin  to 
the  front,  I  have  done  a  version  rather  than  run 
the  chance  of  converting  to  a  posterior  occip- 
ital position  by  flexion  and  then  having  to  run 
the  chance  of  a  persistent  occiput  posterior. 

If  attempts  both  at  conversion  to  a  vertex 
and  podalic  version  fail,  see  what  Nature 
may  accomplish  and  then  if  necessary  apply 
forceps.  I  am  now  speaking  of  a  contingency 
that  I  have  never  had  to  meet.  If  such  should 
arise  I  Avould  perform  a  craniotomy  early  in 
the  attempt  at  forceps  rather  than  run  a  chance 
of  seriously  injuring  the  mother.  In  certain 
selected  cases  Csesarean  section  or  hebotomy 
might  be  indicated. 

In  the  cases  that  I  have  seen,  the  brow  was 
either  in  the  right  posterior  position  and  flex- 
ion of  the  head  and  body  easily  converted  them 
to  the  occiput  left  anterior  position  or  a  ver- 


148  TALKS   ON   OBSTETKICS 

sion  could  be  performed.  These  cases  brought 
home  to  me  and  emphasized  the  importance  of 
early  diagnosis  and  correction  as  soon  as  no 
evidence  was  given  of  natural  resolution  into 
occipital  or  frank  face  presentation  and  before 
firm  engagement  and  molding  of  the  head  or 
the  early  drainage  of  the  amniotic  fluid  might 
make  both  the  correction  to  a  vertex  or  a  ver- 
sion impossible. 


CHAPTER  XIV 
RULES  IN  OBSTETRICS 

1.  Early  pelvimetry  and  pelvic  examination, 
which,  with  an  accurate  past  history  of  the  pa- 
tient, will  allow  of  classification  in  respect  to 
the  coming  delivery,  as  normal,  doubtful  or 
positive  in  relation  to  the  need  of  interference. 

2.  Thorough  physical  and  laboratory  exam- 
ination, to  determine  that  there  are  no  possible 
contraindications  for  entering  the  contest,  such 
as  active  tuberculosis,  severe  heart  or  kidney 
lesions,  or  marked  diabetes. 

3.  Clear  up  all  manifest  foci  of  infection  as 
far  as  is  possible  or  plausible. 

4.  Give  explicit  directions  to  patient  as  re- 
gards general  health  measures  such  as  exercise, 
diet,  baths,  fresh  air,  water  intake  and  atten- 
tion to  bowels. 

5.  Give  explicit  directions  to  the  patient  as 
regards  measures  aimed  at  the  avoidance  of  a 
possible  miscarriage. 

6.  Give  the  patient  a  written  list  of  signs  at 
the  accession  of  w^hich  she  should  notify  you 
immediately.     Such  are:  Persistent  headache, 

149 


150  TALKS   ON   OBSTETRICS 

edema,  disturbance  of  vision,  persistent  consti- 
pation, vaginal  bleeding  or  spotting  or  abdom- 
inal pain  and  vomiting. 

7.  Insist  on  frequent  and  stated  examina- 
tions of  urine  and  blood  pressure. 

8.  Make  no  vaginal  examinations  during  tbe 
last  month  of  pregnancy,  or  during  labor  or 
early  puerperium  unless  the  results  of  abdom- 
inal and  rectal  examinations  leave  one  in  doubt. 

9.  At  the  beginning  of  labor  determine  care- 
fully by  abdominal  and  rectal  examinations, 
the  presentation  and  position. 

10.  Examine  by  rectum  for  a  possible  pro- 
lapsed cord  immediately  after  the  rupture  of 
the  membranes,  especially  if  it  is  not  definitely 
known  that  the  position  and  presentation  are 
normal  and  the  presenting  part  well  engaged. 

11.  Remember  that  the  average  length  of  the 
first  labor  is  about  eighteen  hours  and  of  sub- 
sequent labors  from  twelve  to  fourteen  hours. 

12.  Do  not  interfere  unless  definite  indica- 
tions on  the  part  of  the  mother  or  child  demand. 
It  is  well  to  bear  in  mind  the  approximate  two 
hour  limit  for  the  second  stage  of  labor.  Con- 
ditions may  prompt  its  curtailment  or  ex- 
tension. 

13.  Use  the  most  careful  and  accurate  asep- 


RULES   IN   OBSTETRICS  151 

tic  technic  yourself  and  guard  against  errors  of 
assistants  and  physical  surroundings. 

14.  Do  not  allow  your  patient  to  be  catheter- 
ized  unless  you  feel  that  it  is  absolutely  neces- 
sary. It  is  a  serious  operation  calling  for  the 
best  aseptic  technic.  You  must  catheterize  as 
a  routine  just  before  the  use  of  forceps  or  the 
performance  of  version.  Give  hexamethylen- 
amine  for  a  few  days  following  catheterization. 

15.  Never  use  chloroform  in  any  procedure 
when  a  woman  gives  any  signs  or  symptoms  of 
toxemia. 


INDEX 


Abdominal  Caesarean  in  treat- 
ment of  central  placen- 
ta previa,  81 
indications  for,  137 
Abdominal  examination,  29 
Abortion,  89,  92 
causes  of,  95 
diagnosis,  102 
hemorrhage  in,  92 
induced,  in  pernicious  vom- 
iting, 67 
treatment,  102 
Accidental  hemorrhage,  82 
Acidosis  in  eclampsia,   47 

in  pernicious  vomiting,  67 
Anesthesia  during  pregnancy, 

effect  of,  101 
Asphyxia  as  cause  of  toxemia, 
42 


Bacteria,    entrance    of,    into 
vagina,  25,  26 
in  toxemia,  51 
Bathing  in  pregnancy,  25 
Baths,  spray,  25 

tub,  25 
Bimanual  massage  of  uterus, 
77 


Blood  pressure  in  toxemia,  50 
Bowels,  care  of,  in  sepsis,  38 

in  toxemia,  51 
Breech  delivery,  129 

presentation,  129 
Brow  presentation,  146 

C 

Caesarean   section,   134 
indications  for,  134 
in  toxemia,  57,  59 
Causes   of   toxemias   in   preg- 
nancy, 43 
Cervical  tears,  35 
Chloroform,       contraindicated 
in  cases  of  toxemia,  59 
use  of  in  labor,  116 
poisoning,    experiments    in, 
46 
Convulsions,      during      labor, 
treatment  of,  60 
emptjdng  the  uterus  in,  56 
Cord,  prolapse  of,  126 

D 

Delivery,  breech,  129 

Dental       operations       during 

pregnancy,  99 
Diagnosis     during     labor    by 

rectal    examination,    29 


153 


154 


INDEX 


Diet    in    pernicious   vomiting, 
69 
in  toxemia,  51,  54 
Douche,  contraindicated,  37 
in  pregnancy,  26 
sterile,  in  postpartum  hem- 
orrhage,   77 
Drainage  after  labor,  examin- 
ing for  obstructions  to, 
36 
Drugs,  use  of,  in  labor  prefer- 
able to  forceps,  116 

E 
Early  care  in  pregnancy,  48 
Eclampsia,  41 
acidosis  in,  47 
causes  of,  42 
prophylaxis  of,  44 
treatment  of,  44 
Ectopic  pregnancy,   86 
diagnosis  of,  86 
rupture  of,  88 
symptoms  of,  88 
Emptying  the  uterus  in  tox- 
emia, 58 
Enemas,    nutrient,    in    perni- 
cious vomiting,   70 
Ergot,    extract   of,   in   sepsis, 

37 
Ether»  use  of,  in  cases  of  tox- 
emia, 59 
Examination,       physical,       in 
pregnancy,  48 
rectal,  29 
vaginal,  28 


Face  presentation,  144 
Feeding  in  sepsis,  38 
Floating     head,     delivery     in 

cases  of,  118 
Foci  of  infection,  eradication 
of     as    prevention     of 
sepsis,  25 
in  toxemias,   48 
Forceps,    dangers    in   use    of, 
112 
directions  for  use  of,  120 
in  obstetrics,  112 
Fowler  posture  in  sepsis,  37 

H 

Heart    lesions    in    obstetrics, 

108 
Hemorrhage,  accidental,   82 
treatment  of,  83 
due    to    premature    separa- 
tion of   placenta,   82 
in  abortion,  92 
in  obstetrics,  74 
in  placenta  previa,  78 
postpartum,  74 
causes  of,  75 
treatment  of,  76 


Infection  as  factor  in  abor- 
tion, 96 

as  factor  in  accidental  hem- 
orrhage, 85 

entering  through  lacera- 
tions,   35 


INDEX 


155 


Instructions  to  patients,  need 
of,  24 
to  pregnant  women,  94 
Interference,    indications    for, 
56 
sepsis  due  to,  18 
Invalids  caused  by  sepsis,  19 


Labor  in  hospital,  23 

in  home,   23 
Lacerations  as  point  of  infec- 
tion, 35 
Lues  as  cause  of  abortion,  96 

M 

Magnesium  sulphate,  use  of, 
in  eclampsia,  47 

Male  elements  acting  as  for- 
eign proteins  causing 
pernicious  vomiting,  72 

Massage  of  uterus,  77 

Miscarriage,  92 

at  seventh  month,  107 

Morphin,  use  of,  in  labor,  116 

Murphy  drip  in  convulsions  in 
labor,   60 

N 
Nursing  in  obstetric  cases,  31 

O 

Obstetric  forceps,  112 

nurses,   30 
Obstetrics,  hemorrhage  in,  74 

rules  in,  149 

sepsis  in,  17 


Occiput     posterior     positions, 

140 
rules  of  attack,  142 
Operations  during  pregnancy, 

99 
Oral   cavity,   infection    of,    in 

pregnancy,  48 


Packing    uterus    for    postpar- 
tum hemorrhage,  77 
Perineal  tears,  35 
Pernicious  vomiting,   liver  le- 
sions   associated    with, 
66 
of  pregnancy,  65 
treatment  of,  68 
Phlebotomy,  61,  62 
Physical  examination  in  preg- 
nancy, 48 
Pituitrin,  use  of,  in  labor,  116 
Placenta,   hemorrhage   due   to 
premature       separation 
of,  83 
manual      removal      of,      as 

cause   of   sepsis,   76 
toxin  elaborated  by,  45 
Placenta  previa,  78 
diagnosis  of,  78 
symptoms  of,  78 
treatment  of,  79 
Podalic  version,   122 

indications  for,  122,  123 
Positions,     occiput     posterior, 

140 
Postpartum  hemorrhage,  74 


156 


INDEX 


Pre-eclamptic  toxemia,  41 
Pregnancy,  bathing  in,  25 

douche  in,  26 

early  care  in,  48 

ectopic,  86 

pernicious   vomiting   in,    65 

prophylaxis  in,  94 

toxemias  of,  41 
Premature  separation  of  pla- 
centa,  82 

prevention  of,  84 

treatment  of,  83 
Preparation  of  patient  for  la- 
bor,   32 
Presentation,   breech,   129 

brow,   146 

face,   144 
Prolapse  of  the  cord,  126 
Prophylaxis  in  pregnancy,  94 

in  toxemia,  44 
Psychotherapy,  68 
Puerperal   infection,    39 
Puerperal  rise  of  temperature 
indicative  of  infection, 
39 

E 

Eectal  examination,  28,  29 
Retroverted    uterus    in    preg- 
nancy, 102 
Rules  in  obstetrics,  149 
Rupture   of   ectopic  pregnan- 
cy, 88 
Rupture  of  uterus,  90 
prevention  of,  91 
signs  of,  92 


S 

Scientific    nursing    in    obstet- 
rics, 30 
Sepsis,   causes   of,   22 
due  to  interference,  18 
in   obstetrics,    17 
in  obstetrics,  frequency  of, 

17 
invalids  caused  by,  19 
prevention  of,  in  obstetrics, 

17,  22 
treatment,  37 
Septic  abortion,  treatment  of, 

105 
Spray  bath  in  pregnancy,  25 
Sterile   douche  in  postpartum 
hemorrhage,  77 
T 
Teeth,    care    of   in   pernicious 
vomiting,   69 
in  pregnancy,  99 
Therapeutic  abortion,   72 
advisability  of,  in  tubercu- 
losis, 110 
Toxemia,  emptying  the  uterus 
in,  58 
of  pregnancy,  41 

causes  of,  42 
prophylaxis   in,    44 
symptoms  of,  52 
Toxin  elaborated  by  placenta, 

45 
Treatment  of  pernicious  vom- 
iting, 68 
of  sepsis,  37 
of  toxemia,  44,  54 


INDEX 


157 


Tub  bath  in  pregnancy,  25 
Tuberculosis  in  obstetrics,  108 
Twins,  delivery  of,  132 

U 
Uterine  drainage.  Fowler  pos- 
ture to  promote,  37 
Uterus,  rupture  of,  90 
Urine  in  toxemia,  50,  55 

V 

Vaginal  Csesarean,  indications 
for,  137 


Vaginal  examinations,  28 

contraindicated,  22 
Version,  contraindications,  122 

indications  for,  123 

podalic,  122 
Vorhees  bag,  58 

in    treatment    of    placenta 
previa,  80 

W 

Water  in  sepsis,  28 
Whisky  in  sepsis,  38 


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